Nursing Diagnosis and Nursing Interventions for Dengue Hemorrhagic Fever

Nursing Diagnosis for Dengue Hemorrhagic Fever (DHF)

1. The increase in body temperature related to the process of dengue virus infection.
2. Deficit fluid volume related to the migration of intravascular fluid into extravascular.
3. Impaired nutrition: less than body requirements related to the decreased appetite.

Nursing Interventions for Dengue Hemorrhagic Fever

1. The increase in body temperature related to the process of dengue virus infection.
   
   Goal:
   The body temperature returned to normal
   
   Expected Results:
   • Vital signs within normal limits, especially temperature (36 C - 37 C)
   • Mucous membranes moist.
   
   Nursing Intervention:
   • Observation of vital signs every 1 hour
     Rationale: Determining the continued intervention when changes
   • Give a warm water compress
     Rational: Compress will provide induction heat expenditure.
   • Encourage clients to drink lots of 1500 - 2000 ml
     Rationale: Changing the body fluid that comes out because of heat and spur spending urine.
   • Suggest to wear thin clothes and absorb sweat.
     Rational: To provide a sense of comfort and increase the evaporation heat
   • Observation on the intake and out put
     Rational: Detection of body fluid volume deficiency.
   • Collaboration for the provision of antipyretic
     Rational: Antipyretics useful for heat reduction.
2. Deficit fluid volume related to the migration of intravascular fluid into extravascular
   
   Goal:
   Nothing happens hypovolemic shock
   
   Expected results:
   Blood pressure: 120/80 mmHg, Pulse: 80-100x/mnt, Strong pulse
   
   Nursing Intervention:
   • Observation of vital signs every hour or more. Rationale: Knowing the condition of intra-vascular fluid.
     
   • Observation of capillary refill
     Rational: Indications of adequate peripheral circulation.
   • Observation on the intake and output, record the number, color / concentration of urine.
     Rational: Decrease in urine output / urine is concentrated with an increased density of suspected dehydration.
   • Encourage to drink plenty of 1500-2000 mL
     Rational: To meet the needs of body fluids
   • Collaboration giving intravenous fluids or plasma or blood.
     Rationale: Increasing the amount of body fluids to prevent hypovolemic shock.
3. Impaired nutrition: less than body requirements related to the decreased appetite
   
   Goal:
   Nutrition fulfilled
   
   Results expected:
   • Increased appetite
   • Meal spent
   
   Nursing Intervention:
   • Assess complaints of nausea, vomiting or decreased appetite
     Rationale: Determining the next intervention.
   • Give foods that are easy to swallow and easy to digest
     Rationale: Reduce fatigue and prevent gastrointestinal bleeding.
   • Give small portions of food, but often.
     Rational: Avoiding nausea and vomiting
   • Avoid foods that stimulate: spicy, sour.
     Rationale: Prevent the occurrence of distension of the stomach which can stimulate vomiting.
   • Give the client's favorite foods
     Rationale: Allows for more revenue
   • Collaboration parenteral fluid administration
     Rational: Parenteral nutrition is needed if the peroral intake was less.