DHF - 3 Nursing Diagnosis and Interventions
Formulation of nursing care plan for patients with DHF should refer to the problem of nursing diagnoses are made. Note that the action can be given according to the actions that are independent and collaboration. The author will present the principles of nursing action plan in accordance with the nursing diagnoses:
1. Fluid Volume Deficit related to increased capillary permeability, bleeding, vomiting and fever.
Purpose:
Disorders of body fluid volume can be resolved
Expected outcomes:
Body fluid volume returns to normal
Intervention:
1) Assess the general condition and the condition of the patient.
2) Observation vital signs (temperature, pulse, respiration).
3) Observation for signs of dehydration.
4) Observation drip infusion, and the infusion needle insertion site.
5) Balance fluid (fluid input and output).
6) Give the patient and family encourage patients to give the drink a lot less than from 1500 to 2000 cc per day.
7) Instruct patient's family to replace the patient's clothes were soaked with sweat.
2. Hyperthermia related to dengue virus infection process.
Purpose:
Hyperthermia can be resolved
Expected outcomes:
Body temperature returned to normal
Intervention:
1) Observation vital signs, especially temperature.
2) Give a compress on the forehead and armpits.
3) Change clothes that have been soaked with sweat.
4) Encourage the family to put on clothing that can absorb sweat like cotton.
5) Encourage your family to drink lots of approximately 1500 to 2000 cc per day.
6) Collaboration with doctors in therapy, febrifuge.
c. Imbalanced Nutrition, Less Than Body Requirements related to the nausea, vomiting, no appetite.
Purpose:
Disorders of nutrition is resolved
Expected outcomes:
Nutrient intake increased client
Intervention:
1) Assess the client's nutritional intake and changes.
2) Measure weight loss clients every day.
3) Give the client in warm and eat small portions but often.
4) Give the patient warm water when it complained of nausea.
5) Perform a physical examination Abdomen (auscultation, percussion, and palpation).
6) Collaboration with doctors in anti-emetic therapy.
7) Collaboration with the team in determining nutritional diet.
