Nursing Assessment Example for Dengue Fever
Dengue Fever
Assessment phase of the nursing process is a dynamic process that is organized which includes three basic activities, namely: First, collect data systematically; second, sort and organize the data collected, the third document in a format that can be opened again. (Tarwoto wartonah, 2006)
Assessment in children with Dengue Fever :
a. The identity of the patient
Name, age, gender, address, education, name of parents, parental education, and parental employment.
b. The main complaint
Reasons / a prominent complaint in patients with dengue hemorrhagic fever came to the hospital is a high body temperature and weak.
c. History of present illness
Obtained the existence of sudden heat complaints are accompanied by chills and fever when composmentis consciousness. The decrease of heat occurs between days 3 and 7 and the child is getting weaker. Sometimes accompanied with complaints of cough and cold, pain swallowing, nausea, vomiting, anorexia, diarrhea or constipation, headache, muscle and joint aches, pain uluh liver, and sore eye movement, as well as the manifestation of bleeding in the skin, gums (grade 3 and 4), melena, or hematemesis.
d. Past medical history
Any disease ever suffered. In Dengue Fever, children can experience a repeat attack of Dengue Fever with other types of viruses.
e. Immunization history
If the child has a good immunity, it is likely to be the onset of complications can be avoided.
f. History of nutrition
Nutritional status of children suffering from Dengue fever can vary. All children with good and poor nutritional status may be at risk, if there is a predisposing factor. Children who suffer from DHF often experience nausea, vomiting, and decreased appetite. If this condition persists, and is not accompanied by adequate nutrition, the child may experience weight loss nutritional status becomes less so.
g. Environmental conditions
Frequently occur in densely populated areas and a less clean environment (such as stagnant water and clothes hangers in the room).
h. Patterns
1) The presence of petechiae on the skin, decreased skin turgor, and appears cold sweat, and moisture.
2) Nail cyanosis / no
3) Head and neck
Head ache, face looks reddish because of fever (flusy), eye pallor, sometimes nose bleeding (epistaxis) in grade II, III, IV. In oral mucosa was found that dry mouth, bleeding gums and painful swallowing. While experiencing hyperemia pharing throat (at Grade II, III, IV).
4) Chest
Symmetrical shape and sometimes felt tight. In the thorax there is any liquid that accumulated in the lung to the right (pleural effusion), rales (+), Ronchi (+), which is usually found in grade III and IV.
5) Abdomen
Experiencing tenderness, liver enlargement (hepatomegaly), ascites.
6) Extremities.
Akral cold, and there was muscle pain, joints, and bones.
Assessment phase of the nursing process is a dynamic process that is organized which includes three basic activities, namely: First, collect data systematically; second, sort and organize the data collected, the third document in a format that can be opened again. (Tarwoto wartonah, 2006)
Assessment in children with Dengue Fever :
a. The identity of the patient
Name, age, gender, address, education, name of parents, parental education, and parental employment.
b. The main complaint
Reasons / a prominent complaint in patients with dengue hemorrhagic fever came to the hospital is a high body temperature and weak.
c. History of present illness
Obtained the existence of sudden heat complaints are accompanied by chills and fever when composmentis consciousness. The decrease of heat occurs between days 3 and 7 and the child is getting weaker. Sometimes accompanied with complaints of cough and cold, pain swallowing, nausea, vomiting, anorexia, diarrhea or constipation, headache, muscle and joint aches, pain uluh liver, and sore eye movement, as well as the manifestation of bleeding in the skin, gums (grade 3 and 4), melena, or hematemesis.
d. Past medical history
Any disease ever suffered. In Dengue Fever, children can experience a repeat attack of Dengue Fever with other types of viruses.
e. Immunization history
If the child has a good immunity, it is likely to be the onset of complications can be avoided.
f. History of nutrition
Nutritional status of children suffering from Dengue fever can vary. All children with good and poor nutritional status may be at risk, if there is a predisposing factor. Children who suffer from DHF often experience nausea, vomiting, and decreased appetite. If this condition persists, and is not accompanied by adequate nutrition, the child may experience weight loss nutritional status becomes less so.
g. Environmental conditions
Frequently occur in densely populated areas and a less clean environment (such as stagnant water and clothes hangers in the room).
h. Patterns
- Nutrition and metabolism: frequency, type, abstinence, decreased appetite, decreased appetite.
- Elimination or defecate. Sometimes the child has diarrhea or constipation. While Dengue Hemorrhagic Fever in the grade III-IV could happen melena.
- Elimination of urine or urinating frequent urination needs to be assessed whether a little or a lot of pain or not. In grade IV Dengue Fever frequent hematuria.
- Sleep and rest. Children often experience lack of sleep due to pain / aching muscles and joints so that the quantity and quality of sleep and rest less.
- Cleanliness. Family efforts to maintain personal hygiene and the environment tend to be less, especially to clean mosquito breeding places of Aedes aegypti.
- The behavior and responses when there is a family illness and efforts to maintain health.
- Grade I: composmentis awareness, weak general condition, vital signs and pulse weak.
- Grade II: composmentis awareness, the general state of weakness, and spontaneous bleeding petechiae, bleeding gums and ear, and the pulse weak, small and irregular.
- Grade III: awareness apathetic, somnolent, the general state of weakness, weak pulse, small and irregular, and the tension decreases.
- Grade IV: coma consciousness, vital signs: pulse was not palpable, the tension is not measurable, irregular breathing, cold extremities, sweating, and skin looks blue.
1) The presence of petechiae on the skin, decreased skin turgor, and appears cold sweat, and moisture.
2) Nail cyanosis / no
3) Head and neck
Head ache, face looks reddish because of fever (flusy), eye pallor, sometimes nose bleeding (epistaxis) in grade II, III, IV. In oral mucosa was found that dry mouth, bleeding gums and painful swallowing. While experiencing hyperemia pharing throat (at Grade II, III, IV).
4) Chest
Symmetrical shape and sometimes felt tight. In the thorax there is any liquid that accumulated in the lung to the right (pleural effusion), rales (+), Ronchi (+), which is usually found in grade III and IV.
5) Abdomen
Experiencing tenderness, liver enlargement (hepatomegaly), ascites.
6) Extremities.
Akral cold, and there was muscle pain, joints, and bones.
