Nursing Diagnosis 1. : Hyperthermia related to the process of dengue virus infection.
Goal: Normal body temperature
Outcomes:
Body temperature between 36-37 0 C
Muscle pain disappeared
Intervention:
1. Provide / encourage patients to drink plenty of 1500-2000 cc / day (as tolerated)
Rational: To replace fluids lost due to evaporation.
2. Instruct the patient to wear clothing that is thin and easy to absorb sweat.
Rationale: Providing a sense of comfort and easy thin clothing absorbs sweat and does not stimulate an increase in body temperature.
3. Observation of intake and output, vital signs (temperature, pulse, blood pressure) every 3 hours once or more often.
Rational: Detecting early dehydration and to know the balance of fluids and electrolytes in the body. Vital Signs is a reference to determine the patient's general condition.
4. Collaboration: intravenous fluids and appropriate drug delivery program.
Rationale: Fluid replacement is essential for patients with a high body temperature. Particular drug to lower the patient's body temperature.
Nursing Diagnosis 2. : Risk for Fluid Volume Deficit related to intravascular fluid into the extravascular migration.
Objective: Not happening fluid volume deficit
Outcomes:
Input and output balanced
Vital signs within normal limits
There is no sign of pre-shock
Capilarry refill less than 3 seconds
Intervention:
1. Monitor vital signs every 3 hours / more often.
Rationale: Vital sign help identify fluctuations in intravascular fluid.
2. Observation of capillary refill.
Rational: Indications adequacy of peripheral circulation.
3. Observation of intake and output. Note the color of urine / concentration.
Rationale: Decrease in urine output concentrated suspected dehydration.
4. Suggest to drink 1500-2000 ml / day (as tolerated).
Rational: To consume body fluids orally.
5. Collaboration: intravenous fluid administration.
Rational: It can increase the amount of body fluid, to prevent shock hipovolemic.
Nursing Diagnosis 3. : Risk for Shock Hypovolemic related to excessive bleeding, intravascular fluid into the extravascular migration.
Objective: Not happening hypovolemic shock
Hasl criteria:
Vital signs within normal limits
Intervention:
1. Monitor patient's general condition.
Raional: To monitor the condition of the patient during treatment, especially when there is bleeding. Nurses immediately know the signs of pre-shock / shock.
2. Observation of vital signs every 3 hours or more
Rationale: Nurses need to continue to observe the vital signs to ensure there is no pre-shock / shock.
3. Explain to patients and families sign of bleeding, and immediately report if there is bleeding.
Rationale: By involving the patient and family, then the signs of bleeding can be immediately identified and prompt action, and the right can be given immediately.
4. Collaboration: intravenous fluid administration.
Rationale: Intravenous fluids needed to cope with the severe loss of body fluids.
5. Collaboration: examination: HB, PCV, platelets.
Rationale: To determine the level of leakage of blood vessels experienced by patients and to take further action reference.
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