Minggu, 09 Oktober 2011

Nursing Care

Dengue Hemorrhagic Fever (DHF)


A. DEFINITIONS

Dengue is a viral tropical disease transmitted by mosquitoes and characterized by fever, headache, pain in the limbs, and rash (Brooker, 2001).
Dengue fever / dengue fever is a disease that mainly in children, adolescents, or adults, with clinical signs of fever, sore muscles, or joints accompanied leukopenia, with / without rash (rash) and limfadenophati, biphasic fever, headache severe, pain in the eyeball movement, taste menyecap impaired, mild thrombocytopenia, and bleeding spots (ptekie) spontaneous (Noer, et al, 1999).
Dengue hemorrhagic fever is a disease caused by dengue viruses (arboviruses) that enters the body through the bite of the mosquito Aedes aegypti (Suriadi & Yuliani, 2001).


B. ETIOLOGY

 Bite of the Aedes aegypti mosquito that carries dengue virus (a type of arbovirus). 


C. PATHOFISIOLOGY

Dengue virus enters the body through the bite of aedes aegypti mosquito and then reacted with the antibody and virus-antibody complexes formed, in asirkulasi will activate the complement system (Suriadi & Yuliani, 2001).
Dengue virus enters the body through the bite of mosquitoes and dengue infection was first menyebabkandemam. Body reaction is a reaction commonly seen in infection by the virus. A very different reaction would appear, if someone gets repeated infections with different dengue virus types. And DHF can occur when a person is infected after the first time, got the other dengue virus infection recurs. Re-infection will cause a reaction anamnestik antibody, giving rise to the concentration of antigen-antibody complex (virus-antibody complexes) is high (Noer, et al, 1999).

 
D. CLINICAL MANIFESTATIONS

High fever 5-7 days.
Bleeding, especially bleeding under the skin; ptekie, ekhimosis, hematoma.
Epistaxis, hematemesis, melena, hematuria.
Nausea, vomiting, no appetite, diarrhea, constipation.
Sore muscles, bones and joints, abdomen and solar plexus.
Headache.
Swelling around the eyes.
Enlargement of the liver, spleen and lymph nodes.
Signs of shock (cyanosis, clammy skin, decreased blood pressure, anxiety, capillary reffil time more than two seconds, fast and weak pulse).

E. CLASSIFICATION

WHO, 1986 classifying DHF according to the degree of the disease into four categories, namely:
Grade I: Fever accompanied by other clinical symptoms, without spontaneous bleeding. Heat 2-7 days, positive tourniquet test, trombositipenia, and hemoconcentration.
Degree II: Similar to the degree I, coupled with spontaneous bleeding symptoms such as petechiae, ecchymoses, hematemesis, melena, bleeding gums.
Degree III: Marked by circulatory failure symptoms such as weak and rapid pulse (> 120x/mnt) narrow pulse pressure (120 mmHg), decreased blood pressure, (120/80, 120/100, 120/110, 90/70, 80 / 70, 80 / 0, 0 / 0)
Degrees  IV: Nadi not teaba, blood pressure did not teatur (heart rate 140x/mnt) limb palpable cold, sweating and the skin looks blue.

 
F. DIAGNOSTIC EXAMINATION

Drink lots of 1.5 liters - 2 liter/24 hours (with tea, sugar, milk).
Antipyretics if there is fever.
Anticonvulsants if there are seizures.
Giving fluids through an IV, performed if the patient has difficulty drinking and hematocrit values ​​tended to increase.

NURSING MANAGEMENT
  
A. Assessment

1. Identity
    
DHF is a tropical disease that often causes the death of children, adolescents and adults (Effendy, 1995).
 
2. Main complaint
    
Patients complain of fever, headache, weakness, heartburn, nausea and decreased appetite.
 
3. History of present illness
    
Medical history showed headache, muscle pain, soreness throughout the body, pain on swallowing, weakness, fever, nausea, and decreased appetite.
 
4. History of previous illness
    
No illness is specific.
 
5. Family history
    
A history of DHF disease in other family members is crucial, because the disease DHF is a disease that can be transmitted through mosquito bites aigepty aides.
 
6. Environmental Health History

Normally less clean environment, lots of water puddles like cans, old tires, where water birds are rarely replaced drink water, bathtubs rarely cleaned.
 
7. Growth History
 
8. Per Assessment System

*      Respiratory System
Tightness, bleeding through the nose, shallow breathing, epistaxis, symmetrical chest movements, resonant percussion, auscultation sounds Ronchi, krakles.

*      Nerve System
In grade III patients with anxiety and a decline in awareness and in grade IV can trjadi DSS


*      Cardiovascular system
In grde I hemoconcentration can occur, positive tourniquet test, trombositipeni, in grade III circulatory failure may occur, rapid pulse, weakness, hypotension, cyanosis around the mouth, nose and fingers, in grade IV no palpable pulse and blood pressure can not be measured.

*      Digestive System
Dry mucous membranes, difficulty swallowing, epigastric tenderness, pembesarn spleen, enlarged liver, abdominal stretch, decreased appetite, nausea, vomiting, pain on swallowing, can hematemesis, melena.


*      Urinal system
Urine production declines, sometimes less than 30 cc / hour, will reveal sat painful urination, urine red.

*       Integumentary system.
An increase in body temperature, dry skin, the grade I found a positive tourniquet test, occurred pethike, in grade III bleeding can occur spontaneously in the skin. 

B. Nursing Diagnosis

1.      Hipertermi associated with dengue virus infection process.
2.      Risks associated with the moving fluid deficit intravascular to extravascular fluid.
3.      Risk of nutritional disorders needs less than body requirements related to inadequate nutritional intake due to nausea and decreased appetite.
4.      The risk of bleeding associated with decreased blood clotting factors (thrombocytopenia).
5.       Parental anxiety associated with the child's condition.
6.      Lack of knowledge about the family illness, prognosis, the effect of the procedure, and care of sick family members associated with less exposure / recall information.
1.    

C. Nursing Care Plan.

DP 1             : Hipertermie associated with the process of dengue virus infection
Objectives    : Normal body temperature
Criteria         : - The body temperature between 36-37
                       - Muscle pain disappear
Intervention  :
a. Assess the patient's body temperature
    Rational: to know the increase in body temperature, facilitate intervention
b. Apply warm water
    Rationale: reduce heat by conduction heat transfer. Warm water gently control the heat
     transfer without causing hypothermia or shivering.
c. Provide / encourage patients to drink plenty of 1500-2000 cc / day (according to tolerance)
    Rational: To replace fluids lost due to evaporation.
d. Instruct the patient to wear clothing that is thin and easily absorbs sweat
    Rationale: Providing a sense of comfort and clothes that thin easily absorb sweat and does not
     stimulate an increase in body temperature.
e. Observation intake and output, vital signs (temperature, pulse, blood pressure) once every 3
     hours or as indicated
    Rationale: Early detection and knowing the lack of fluid and electrolyte balance in body
     fluids. Vital Signs is a reference to determine the patient's general condition.
f. Collaboration: Intravenous fluid administration and drug delivery based on the program.
     Rationale: The provision of fluids is very important for patients with high body temperature.
     Drugs in particular to reduce the patient's body heat.

DP 2             : The risk of fluid volume deficit related to movement of intravascular fluid into
                       extravascular.
Purpose         : Not voume fluid deficit
Criteria          : - Input and output balanced
                       - Vital signs within normal limits
                       - No sign of presyok
                      - Akral warm
                       - Capilarry refill <2 seconds
Intervention  :
a. Keep an eye on vital signs every 3 hours / as indicated
    Rational: Vital sign helps identify fluctuations in intravascular fluid
b. Observation of capillary refill
    Rational: Indications adequacy of peripheral circulation
c. Observation intake and output. Note the color of urine / concentration, BJ
    Rationale: Decreased urine output concentrated with an increase in BJ suspected dehydration.
d. Suggest for drinking 1500-2000 ml / day (according to tolerance)
    Rationale: To meet the needs of body fluids orally
e. Collaboration: Giving intravenous fluids
    Rational: May increase the amount of body fluid, to prevent the occurrence of shock
     hipovolemic.

DP 3             : The risk of hypovolemic shock associated with excessive bleeding, fluid
                       movement of intravascular to extravascular.
Objectives    : No hypovolemic shock
Criteria         : - Vital signs within normal limits
 
Intervention  :
a. Monitor patient's general condition
    Rationale: To monitor the condition of the patient during treatment, especially when paused
     bleeding. The nurse immediately know the signs presyok / shock.
b. Observation of vital signs every 3 hours or more
    Rationale: Nurses need to continue mengobaservasi vital signs to ensure it does not happen
     presyok /shock.
c. Explain to the patient and family sign of bleeding, and immediately report if there is bleeding
    Rationale: By involving the family psien and signs of bleeding can be immediately known
     and a quick and appropriate action can be given immediately.
d.  Collaboration: Giving intravenous fluids
    Rationale: Intravenous fluids are needed to overcome the great loss of body fluids.
e. Collaboration: checks: HB, PCV, platelet
    Rationale: To determine the rate of leakage of blood vessels that experienced by patients and
     to reference further action.

DP 4             : Risk of impaired nutritional needs less than body requirements related to
                       inadequate nutritional intake due to nausea and decreased appetite.
Objectives    : No interference occurs nutritional needs
Criteria         : - There are no signs of malnutrition
                       - Shows a balanced weight.
 
Intervention  :
a. Review the history of nutrition, including foods that are preferred
    Rationale: Identify deficiencies, suspect the possibility of intervention
b. Observation and record patient's food intake
    Rational: Keep an eye on caloric intake / food consumption shortage of quality
c. Weigh the BB every day (if possible)
    Rational: Keep an eye on weight loss / oversee the effectiveness of interventions.
d. Give small, frequent meals or eating between meals
    Rationale: Food can decrease a little weakness and increased input also prevent gastric
     distention.
e. Give and oral hygiene aids.
    Rationale: Increased appetite and input peroral
f. Avoid foods that stimulate and contain gas.
    Rational: Lowering distention and gastric irritation.

DP 5             : The risk of bleeding associated with decreased blood clotting factors
                       (thrombocytopenia)
Objectives    : No bleeding
Criteria         : - BP 100/60 mmHg, N: 80-100x/menit regular, strong pulse
                       - No sign of further bleeding, platelets increase.

Intervention  :
a. Monitor signs of decreased platelets are accompanied by clinical signs.
    Rationale: The reduction in platelet count is a sign of leakage of blood vessels at a certain
     stage can cause clinical signs such as epistaxis, ptike.
b. Instruct patient to take plenty of rest (bed rest)
    Rational: Activity patients can cause uncontrolled bleeding.
c. Give an explanation to clients and families to report any signs of bleeding such as
     hematemesis, melena, epistaxis.
    Rationale: The involvement of patients and families can help to penaganan early if there is
     bleeding.
d. Anticipation of bleeding: use a soft toothbrush, pet oral hygiene, give it 5-10 minutes after
     each pressure take blood.
    Rationale: Prevent the occurrence of further bleeding.
e. Collaboration, monitor platelet counts every day
    Rationale: With the platelets are monitored every day, can know the level of leakage of blood
     vessels and the possibility of bleeding experienced by patients.

DP 6             : parental anxiety associated with the child's condition.
Objective      : Anxiety is reduced / controlled.
Criteria         : - the client reported no physical manifestations of anxiety.
                       - There is no manifestation of behavior due to anxiety.

Intervention  :
a. Assess and document the patient's anxiety level.
    Rational: to facilitate intervention.
b. Assess patient's coping mechanisms used to cope with anxiety in the past.
    Rational: to maintain adaftif coping mechanisms, increasing the ability to control anxiety.
c. Do the approach and give motivation to the patient to express thoughts and feelings.
    Rational: the approach and motivation to help the patient to mengeksternalisasikan perceived
     anxiety.
d. Patient's motivation to focus on the reality that exists today, expectations are positive towards
     terapy in live.
    Rational: a tool to identify the coping mechanisms needed to reduce anxiety.
e. Give positive reinforcement to continue daily activities while in a state of anxiety.
    Rational: to create a sense of trust in the patient that he was able to overcome the problem and
     give confidence to yourself sendri as evidenced by the recognition of others for his ability.
f. Instruct the patient to use relaxation techniques.
     Rational: to create a calm and comfortable feeling.
g. Provide factual information (real and true) to the patient and family regarding the diagnosis,
     treatment and prognosis.
    Rational: to increase knowledge, reduce anxiety.
h. Collaboration antianxiety drug administration.
    Rational: to reduce anxiety as needed.

DP 7             : Lack of family knowledge about the disease, prognosis, the effect of the
                       procedure, and care of sick family members associated with less exposure / recall
                       information.
Objectives    : Parents expressed an understanding of the conditions, procedures and treatment
                       process effects.
Criteria         : - perform the necessary procedures and explain the reason of an action.
                       - Initiate the necessary lifestyle changes and participate in a treatment regimen.

Intervention  :
a. Assess the level of knowledge of the client and family about the disease.
    Rational: to know how much experience and knowledge of the client and family about the
     disease.
b. Give an explanation on the client and family about his illness and his condition now.
    Rational: to know the diseases and conditions are present, the client and his family will feel
     calm and reduce anxiety.
c. Encou age clients and families to pay attention to his diet.
    Rational: diet and proper diet helps the healing process.
d. Encourage families to consider self-care and environment for a sick family member. Do /
     demonstrate self care techniques and client environment.
    Rational: personal care (bathing, toileting, dressing / makeup) and environmental hygiene is
     important to create a feeling of comfort / relaxed ill clients.
e. Ask the client / family to repeat back the material that has been given.
    Rational: to know how much understanding the client and family as well as assessing the
     success of the action taken.

D. Evaluation

1. Normal body temperature
2. Fluid does not occur devisit voume
3. Hypovolemic shock does not occur
4. No interference occurs nutritional needs
5. No bleeding
6. Anxiety is reduced / controlled
7. parents understand about the conditions, procedures and treatment process effects.


REFERENCES

Hidayat, Aziz A. Alimul 2006. Introduction to Nursing Children vol 2. Salemba Medika: Jakarta
Nasrul, Effendi. 1995. Introduction to Nursing Process. EGC: Jakarta
Noer, Sjaifoellah et al. 1998. Patient Care Standards. Monica Esther: Jakarta.
Suriadi & Yuliani, Rita. 2001. Handbook of Clinical Practice: Nursing Care in Children. Sagung Seto: Jakarta

Picture of  Dengue Hemorrhagic Fever (DHF)

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http://2.bp.blogspot.com/-Z90iufYyb58/TpJ-wfLJPMI/AAAAAAAAAAQ/Oe-BpmU02Ok/s200/images.jpeg

http://1.bp.blogspot.com/-Q6X8opHzLls/TpJ-wnYOP9I/AAAAAAAAAAU/uRBGPG518lQ/s200/images1.jpeg


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