Minggu, 03 Maret 2013

Dengue Hemorrhagic Fever (DHF)


Dengue Hemorrhagic Fever (DHF) 


A. DEFINITIONS 
Dengue is a viral disease of tropical areas that are transmitted by mosquitoes and characterized by fever, headache, pain in the limbs, and rash (Brooker, 2001). 
Dengue / Dengue fever is a disease primarily in children, adolescents, or adults, with clinical signs of fever, muscle aches, or joint with leukopenia, with / without rash (rash) and limfadenophati, biphasic fever, headaches severe, pain in the eye movements, impaired sense menyecap, mild thrombocytopenia and bleeding spots (ptekie) spontaneous (Noer, et al, 1999). 
Dengue hemorrhagic fever is a disease caused by dengue viruses (arboviruses) that enter the body through the bite of Aedes aegypti (Suriadi & Yuliani, 2001). 

B. Etiology 
 bite of Aedes aegypti mosquito that carries dengue virus (a type of arbovirus). 


C. FATOFISIOLOGI 
Dengue virus enters the body through the bite of aedes aegypti mosquito and then reacted with antibodies and virus-antibody complexes formed in asirkulasi activates the complement system (Suriadi & Yuliani, 2001). 
Dengue virus enters the body through the bite of mosquitoes and dengue infections menyebabkandemam first. Body's reaction is a reaction commonly seen in infections by viruses. Very different reactions will appear, if a person gets repeated infections with different dengue virus types. And DHF can occur when a person once infected the first time, got the other dengue virus infection recurring. Re-infection will cause a reaction anamnestik antibody, resulting in the concentration of antigen-antibody complexes (antibody-virus complexes) high (Noer, et al, 1999). 
D. CLINICAL 
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, the pulse rapid and weak). 
E. CLASSIFICATION 
WHO, 1986 DHF classified according to the degree of the disease into 4 groups, namely: 
Grade I: Fever accompanied by other clinical symptoms, no spontaneous bleeding. Heat 2-7 days, positive tourniquet test, trombositipenia, and hemoconcentration. 
Grade II: Same as grade I, coupled with spontaneous bleeding symptoms such as petechiae, ecchymosis, hematemesis, melena, bleeding gums. 
Grade 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) 
Degree IV: Nadi no teaba, teatur blood pressure (heart rate  140x/mnt) limbs felt cold, sweating and the skin looks blue. 
F. DIAGNOSTIC EXAMINATION 
 Drink lots of 1.5 liters - 2 liter/24 hours (with water tea, sugar, milk). 
 Antipyretics if there is a fever. 
 anticonvulsants if there is a seizure. 
 Giving intravenous fluids, performed if the patient has difficulty drinking and hematocrit values ​​tend to increase. 

NURSING MANAGEMENT 
A. Assessment 
1. Identity 
DHF is a tropical disease that often leads to the death of children, adolescents and adults (Effendy, 1995). 
2. Main complaint 
Patients complain of heat, headache, weakness, heartburn, nausea and decreased appetite. 
3. History of present illness 
Medical history showed headache, muscle aches, the whole body aches, pain on swallowing, weakness, heat, nausea, and decreased appetite. 
4. History of previous illness 
There is no a specific illness. 
5. Family history of disease 
History of DHF disease in other family members is crucial, since DHF disease is a disease that can be transmitted through mosquito bites aigepty aides. 
6. Environmental Health History 
Usually less than clean environment, many puddles of water like tin cans, old tires, a water bird that rarely changed the water, the tub is rarely cleaned. 
7. Developmental History 
8. Per Assessment System 
 Respiratory System 
Spasms, bleeding through the nose, shallow breathing, epistaxis, symmetrical chest movement, resonant percussion, auscultation sounds ronchi, krakles. 
 Systems Persyarafan 
In grade III patient anxiety and a decline in awareness and in grade IV DSS can trjadi 
 cardiovascular system 
In grde I hemoconcentration can occur, positive tourniquet test, trombositipeni, the 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 could not be measured . 
 Digestive System 
Dry mucous membranes, difficulty swallowing, epigastric tenderness, pembesarn spleen, liver enlargement, abdominal stretch, decreased appetite, nausea, vomiting, pain on swallowing, may hematemesis, melena. 
 urinary system 
Decreased urine production, sometimes less than 30 cc / hour, will reveal sat urinary pain, red urine. 
 Integumentary System. 
An increase in body temperature, dry skin, the grade I are positive tourniquet test, there pethike, the grade III bleeding can occur spontaneously in the skin. 
B. Nursing Diagnosis 
1. Hyperthermia associated with dengue virus infection process. 
2. Risks associated with the moving fluid deficit intravascular to the extravascular fluid. 
3. Hypovolemik shock risk associated with excessive bleeding, intravascular to the extravascular fluid displacement. 
4. Risk of nutritional disorders needs less than body requirements related to inadequate nutrition intake due to nausea and decreased appetite. 
5. Risk of bleeding associated with a decrease in blood clotting factors (thrombocytopenia). 
6. Parental anxiety related to the child's condition. 
7. Lack of knowledge about family illness, prognosis, effect of the procedure, and care for sick family members associated with low exposure / recall information. 
C. Nursing care plan. 
DP 1: Hipertermie associated with dengue virus infection process 
Objective: Normal body temperature 
Criteria: - The body temperature between 36-37 
- Muscle pain is gone 
Intervention: 
a. Assess the patient's body temperature 
Rational: find an increase in body temperature, facilitate intervention 
b. Give warm compresses 
Rational: reduce heat to heat transfer by conduction. Warm water is slowly control the heat removal without causing hypothermia or shivering. 
c. Provide / encourage patients to drink plenty of 1500-2000 cc / day (as tolerated) 
Rationale: To replace fluids lost due to evaporation. 
d. Instruct patient to wear clothes that are thin and easy to absorb sweat 
Rationale: To provide a sense of comfort and wear thin easily absorbs 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 Detect hydrated and knowing fluid and electrolyte balance in the body. Vital Signs is a reference to determine the patient's general condition. 
f. Collaboration: intravenous fluid and drug delivery according to the program. 
Rationale: Proper hydration is very important for patients with a high body temperature. Particular drug to lower a patient's body heat. 
DP 2: Risk of fluid volume deficit related to the displacement of the intravascular to the extravascular fluid. 
Objective: Not voume fluid deficit 
Criteria: - Input and output balanced 
- Vital sign within normal limits 
- No sign of presyok 
- Akral warm 
- Capilarry refill <2 seconds 
Intervention: 
a. Monitor vital sign every 3 hours / appropriate indications 
Rationale: 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 with increased BJ concentrated suspected dehydration. 
d. Encourage to drink 1500-2000 ml / day (as tolerated) 
Rationale: To meet the needs of the body fluids peroral 
e. Collaboration: Intravenous Fluid 
Rational: It can increase the amount of body fluid, to prevent hipovolemic shock. 
DP 3: The risk of hypovolemic shock associated with excessive bleeding, intravascular to the extravascular fluid displacement. 
Objective: Did not happen hypovolemic shock 
Criteria: - Vital signs within normal limits 
Intervention: 
a. Monitor the patient's general condition 
Rationale: For monitoring the condition of the patient during treatment, especially when paused bleeding. Nurses immediately know the signs presyok / shock. 
b. Observation of vital sign every 3 hours or more 
Rationale: Nurses need to continue mengobaservasi vital sign to ensure it does not happen presyok / shock. 
c. Explain to the patient and family sign of bleeding, and immediately report if bleeding occurs 
Rationale: By involving the family psien and signs of bleeding can be quickly identified and appropriate action is fast and can be immediately given. 
d. Collaboration: Intravenous Fluid 
Rationale: Intravenous fluids needed to overcome a severe loss of body fluids. 
e. Collaboration: checks: HB, PCV, platelet 
Rationale: To determine the level of blood vessel leakage experienced by patients and to take further action reference. 
DP 4: Risk of impaired nutritional needs less than body requirements related to inadequate nutritional intake due to nausea and decreased appetite. 
Goal: No interference nutritional needs 
Criteria: - There is no sign of malnutrition 
- Demonstrate a balanced weight. 
Intervention: 
a. Review the history of nutrition, including food preferences 
Rationale: Identify deficiencies, suspect a possible intervention 
b. Observation and record the patient's food intake 
Rational: Supervise caloric intake / quality of food consumption shortfall 
c. BB Weigh every day (if possible) 
Rational: Supervise weight loss / oversee the effectiveness of interventions. 
d. Give food a little but often and or eating between meals 
Rational: little food can reduce vulnerabilities and increase input also prevent gastric distention. 
e. Give and Bantu oral hygiene. 
Rationale: Increased appetite and input peroral 
f. Avoid foods that stimulate and gassy. 
Rationale: Reducing distention and gastric irritation. 
DP 5: Risk of bleeding associated with a decrease in clotting factors of blood (thrombocytopenia) 
Objective: Do not bleed 
Criteria: - TD 100/60 mmHg, N: 80-100x/menit regular, strong pulsation 
- No sign of further bleeding, platelets increase. 
Intervention: 
a. Monitor signs of decreased platelets accompanied by clinical signs.
Rationale: Platelet decline is a sign of leaking blood vessels at a certain stage can cause clinical signs such as epistaxis, ptike. 
b. Instruct patient to a lot of breaks (bedrest) 
Rationale: Activity patients can lead to uncontrolled bleeding. 
c. Provide explanations 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, maintain oral hygiene, apply pressure after every 5-10 minutes take blood. 
Rationale: Prevent further bleeding. 
e. Collaboration, monitor platelets every day 
Rationale: The platelets are monitored every day, it can be seen the level of vascular leakage and possible bleeding experienced by the patient. 
DP 6: parental anxiety related to the child's condition. 
Objective: Anxiety is reduced / controlled. 
Criteria: - client reported no physical manifestations of anxiety. 
- No manifestations of behavior due to anxiety. 
a. Assess and document the patient's level of anxiety. 
Rational: to facilitate intervention. 
b. Assess the patient's coping mechanisms used to cope with anxiety in the past. 
Rational: maintaining adaftif coping mechanisms, improve the ability to control anxiety. 
c. Approach and provide motivation to patients to express their thoughts and feelings. 
Rational: approach and motivation to help patients to externalise anxiety felt. 
d. The motivation of patients to focus on the current reality, positive expectations towards terapy that live. 
Rationale: a tool to identify the coping mechanisms needed to reduce anxiety. 
e. Give positive reinforcement to continue their daily activities in spite of the anxiety. 
Rational: creating confidence in the patient that he was able to overcome the problem and give confidence in yourself sendri as evidenced by the recognition of others in his abilities. 
f. Instruct the patient to use relaxation techniques. 
Rational: creating a sense of calm and comfortable. 
g. Provide factual information (real and true) to patients and families regarding diagnosis, treatment and prognosis. 
Rational: to increase knowledge, reduce anxiety. 
h. Collaboration of antianxiety drugs. 
Rational: to reduce anxiety as needed. 
DP 7: Lack of knowledge about family illness, prognosis, the effect of the procedure, and care for sick family members related to lack of exposure / recall information. 
Objective: parents expressed an understanding of the conditions, procedures and treatment process effects. 
Criteria: - perform the necessary procedures and explain the reason of an act. 
- Initiate the necessary lifestyle changes and participate in treatment regimen. 
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. Provide a description of the client and family about his illness and his condition now. 
Rational: by knowing the disease and its present state, the client and his family will feel calm and reduce anxiety. 
c. Instruct client and family to watch his diet. 
Rational: diet and proper diet helps the healing process. 
d. Encourage families to pay attention to personal and environmental care for a sick family member. Perform / demonstrate self-care techniques and client environments. 
Rational: personal care (bathing, toileting, dressing / dress) and a clean environment is important to create a feeling of comfort / relaxation ill client. 
e. Ask the client / family to repeat back the material that has been given. 
Rational: knowing how much understanding of clients and their families and assess the success of the action taken. 
D. Evaluation 
1. Normal body temperature 
2. Did not happen voume fluid deficit 
3. Did not happen hypovolemic shock 
4. No interference nutritional needs 
5. No bleeding 
6. Anxiety is reduced / controlled 
7. parents understand about the conditions, procedures and treatment process effects. 
REFERENCES 
Hidayat, A. Aziz Alimul , 2006. Introduction to Nursing Children jilid.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 

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