CHAPTER I

INTRODUCTION

A. BACKGROUND
DHF (Dengue Haemorragic Fever) in ordinary people is often referred
to as dengue fever. According to experts, dengue hemorrhagic fever is referred
to as a disease (especially often encountered) caused by dengue virus with the
main symptoms of fever, muscle pain, and joints followed by symptoms of
spontaneous bleeding such as red spots on the skin, nosebleeds even in severe
conditions accompanied by vomiting and bloody chapter.
Dengue Hemorrhagic Fever is one of the most common arbovirus
infections appearing in the tropics and subtropics throughout the world. The
infection is spread by mosquitoes which cause swelling fever and bleeding in
the lymph node. Also causes severe pain in the muscles and joints, this is often
suffered by children under the age of 10 years and the infection can recur again
the following year (Mursalim, 2011).
Mortality and morbidity caused by infectious diseases is still high,
especially those caused by DHF.
According to the Indonesian Ministry of Health (2015). In 2014, until
mid-December, there were 71,668 Dengue Fever sufferers in 34 provinces in
Indonesia, and 641 of them died. Based on data released by the Ministry of
Health, the number of dengue cases as of January 29, 2019 reached 13,683 with
133 deaths. The number continues to increase marked by the number of dengue
cases until February 3, 2019 which reached 16,692 cases and 169 of them were
declared dead. The most cases are in East Java, Central Java, NTT, and Kupang
. DHF disease is a health problem that still requires serious prevention
and control, because there are not a few numbers of morbidity and mortality
that occur due to DHF. This disease does not only affect adults and adolescents
but also attacks children.
 DHF has a very fast course and often becomes fatal because many
patients die from late treatment. (Widoyono, 2011) The role of nurses in DHF
is one of them is providing information to sufferers of DHF, to avoid the
possibility of further effects. There are so many adverse effects that occur in
DHF, therefore it is very important that nurses provide information about DHF.
In addition, the nurse's role is as an advocate. Based on this background, the
authors raised this case as learning material in efforts to deal with DHF (Dengue
Haemorragic Fever).

B. Objectives
1. General Objectives

Knowing nursing care to patients with DHF (Dengue Haemorragic Fever)

2. Specific Purpose

a. Knowing the concept of nursing care to patients with DHF (Dengue Haemorragic
Fever)

b. Knowing how to provide nursing care to patients with DHF (care to patients with
DHFDengue Haemorragic Fever)

c. Knowing how to document nursingpatients with DHF (Dengue Haemorragic

Fever)
C. Benefits

Can be used as a guideline in the provision of nursing care to patients with DHF
(Dengue Haemorragic Fever)
 CHAPTER II
BASIS OF THEORETICAL

CONCEPT OF THE BASIC CONCEPT OF

1. DHF DEFINITION
fever (Dengue haemorrhagicDHFDHF) is an infectious disease caused by
dengue virus with clinical manifestations of fever, muscle aches, and / or joint pain
accompanied by leukopenia, rash, lymphadenopathy,) thrombocytopenia, and
hemorrhagic testing. In DHF, plasma leakage occurs which is characterized by
hemoconcentration (increased hematocrit) or a buildup of fluid in the body cavity.
(Sudoyo Aru in Nurarif, 2015)

2. CAUSES / FACTORS OF DHF PREDISPOSITION Dengue

viruses include the genus Flavivirus, the flaviridae family serologically there
are 4 types of DEN-1, DEN-2, DEN-3, and DEN-4. All four are found in Indonesia
with the most DEN-3 serotypes. Infection of one serotype will cause antibodies to
the serotype concerned, while the serotype formed against other serotypes is very
lacking, so it cannot provide adequate protection against the other serotypes. A
person who lives in a dengue endemic area can be infected by 3 or 4 serotypes
during his life. The four dengue virus serotypes can be found in various regions in
Indonesia (Sudoyo Aru in Nurarif, 2015).
This disease is caused by the dengue virus and transmitted by Aedes
mosquitoes. In Indonesia there are two types of Aedes mosquitoes, namely:
a. Aedes Aegypti, namely:
- Most often found
- are mosquitoes that live in the tropics, especially living and breeding in the
house, namely in clear water reservoirs or water reservoirs around the
house.
- This mosquito cursory glance, white spots. Usually bite in the afternoon,
especially in the morning and evening.
 - The flight distance of 100 meters
b. Aedes Albopictus, namely:
- Place its habitat in the place of clean water. Usually around the house or
trees, such as banana trees, pandanus used cans
- Biting at noon
- Flying distance of 50 meters.

3. Pathophysiology of DHF Dengue

virus that has entered the body of the patient will cause viremia (the virus is
in the blood circulation). This causes the activation of complement, resulting in an
immune complex. Antibodies - the activation virus will form and release C3a, C5a,
bradykinin, serotinin, thrombin, Histamine) substances, which will stimulate
PGE2 in the Hypothalamus, resulting in instable regulation thermo, namely
hyperthermia which will increase Na + reabsorption and water resulting in
hypovolemia. Hypovolemia can also be caused by increased permeability of blood
vessel walls which causes leakage of the palms. The presence of antibody-virus
immune complexes also results in platelet aggregation resulting in impaired
platelet function, thrombocytopenia, and coagulopathy. All three of these cause
excessive bleeding which if shock continues and if shock is not resolved, tissue
hypoxia will occur and eventually metabolic acidosis occurs. Metabolic acidosis
is also caused by plasma leakage which eventually weakens the systemic
circulation so that tissue perfusion decreases and if not treated can cause tissue
hypoxia.
The incubation period of dengue virus is 3-15 days, on average 5-8 days.
Viruses can only live in living cells, so they must compete with human cells,
especially in protein needs. The competition is very dependent on the endurance
of the human body. As a reaction to infection occurs:
1) Dengue virus will enter the body through the bite of the Aedes Aegepty
mosquito and then it will react with antibodies and the antibody virus complex
is formed, in the circulation will activate the complement system. As a result of
 the activation of C3 and C5, C3a and C5a are released, 2 peptides are powerful
to release histamine and are strong mediators as a factor in elevating the
permeability of blood vessel walls and removing plasma through the endothelial
wall.
2) Thrombocytopenia, decreased platelet function and decreased coagulation
factors (protrobin, factors V, VII, IX, X and fibrinogen) are factors that cause
severe bleeding, especially gastrointestinal tract bleeding in DHF.
3) What determines the severity of the disease is the permeability of blood vessel
walls, decreased plasma volume, the occurrence of hypotension,
thrombocytopenia and hemorrhagic diathesis, shock occurs acutely.
4) The hematocrit value increases with the loss of plasma through the endothelial
wall of the arteries. and with the loss of plasma the client experiences
hypovolemia. If not treated, tissue anoxia, metabolic acidosis and death can
occur. (Suriadi and Rita Yuliani, 2006)
PATHWAY

Arbovirus (melalui Beredar dalam aliran Mengaktifkan sistem Membuat dan PGE Hipotalamus
nyamuk aedes aegypti darah komplemen melepas zat C3a, C5a

Acites Abdomen Renjatan hipovolemik Risiko syok Hipertermi

dan hipotensi hipovolemik
Defisit nutrisi

Mual, muntah Reabsorpsi Na dan

Nausea H2O meningkat

Kebocoran plasma ke
Penekanan Hepatomegali Hepar Kerusakan endotel Permeabilitas
ekstravaskuler
intraabdomen pembuluh darah meningkat

Nyeri akut Perdarahan Agresi trombosit

Risiko
ketidakseimbangan Risiko perfusi jaringan Trombositopeni
cairan tidak efektif
Benda asing Efusi plura Paru-paru
dalam jalan
Risiko perdarahan
napas
Hipoksia jaringan

Bersihan jalan
napas tidak efektif Asidosis metabolik

Risiko syok
 4. CLASSIFICATION DHF
According to Suriadi (2010) the degree of DHF disease is classified into 4
groups, namely:
- Degree I: fever accompanied by other clinical symptoms, without spontaneous
bleeding. Positive tourniquet test, thrombocytopenia and hemoconcentration.
- Degree II: same as degree I, plus symptoms of spontaneous bleeding.
- Grade III: marked by symptoms of circulatory failure such as weak and fast
pulse (> 120 x / min) narrow pulse pressure (<120 mmHg), cold and moist skin
and restlessness.
- Grade IV: severe shock accompanied by palpable pulses and irregular blood
pressure.
Classification of DHF degrees according to WHO:
- Degree 1: fever with non-typical symptoms and the only manifestation of
bleeding is a positive tornoquet test
- Degree 2: degree 1 accompanied by spontaneous bleeding in the skin and / or
other bleeding.
- Grade 3: signs of circulatory failure are found, namely rapid and gentle pulse,
decreased pulse pressure (<20mmHg) or hypotension with cold, moist skin and
the patient becomes restless.
- Symptom 4: severe shock, pulses are not palpable and blood pressure cannot be
measured.

5. DHF CLINICAL MANIFESTATIONS

Based on WHO 1997 criteria the diagnosis of DHF is made when all of the
following are fulfilled:
a. Fever: Initially acute, quite high, and continuous, lastingdays
b. Bleeding manifestations which usually include:
- 2-7Positive torniquet test
- Petechia, purpura, ecchymosis,
 - haemorrhage mucosa (epistaxis, bleeding gums), gastrointestinal tract,
injection site.
- Hematemesis or melena
c. Thrombocytopenia <100.00 / mm3
d. Leakage of plasma which is characterized by
- increased value of hematocrit  20% of the standard value according to age
and gender
- Impairment hematockit  20% after administration of adequate fluid
e. Signs of plasma leakage such as: hipoproteinemi, ascites, pleural effusion

In the course of dengue infection, there are three phases of the course of dengue
infection, namely:

1. Day 1-3 High Fever Phase

Sudden high fever, and accompanied by severe headaches, pain behind the eyes, body
aches and pain, and nausea / vomiting, sometimes accompanied by red spots
on the skin.
2. Days 4 - 5 Critical
Phase The fever phase drops dramatically and is often deceptive as if healing has taken
place. But this is a critical phase of the possibility of "Dengue Shock
Syndrome"
3. Day 6 - 7 Healing
Phase The fever phase is high again as part of the reaction to the healing stage.

6. EXAMINATION OF DHF SUPPORT

1) Complete blood tests for
- hemoglobin and PCV increased (> 20%)
- Thrombocytopenia (<100,000 / mm3)
- Leukocytes decreased on days 2 and 3
- Low blood protein
- Ureum and PH may increase
 - NA and CL low
- Serology: HI (hemaglutination inhibition test).
2) Chest X-ray: It is supporting data to determine the possibility of pleural effusion
found. Tourniquet
3) test (+)
4) Ultrasound: to detect the presence of hepatomegaly and splenomegaly.

7. ADMINISTRATION OF DHF
Management for DHF clients is treatment in grade I to grade IV.
1. Degrees I and II
a. Providing adequate fluids with RL infusion at a dose of 75 ml / kg body
weight / day for children weighing less than 10 kg or together with oralit,
fruit water or enough milk, or administering fluids within 24 hours include
the following: :
- 100 ml / kg BW / 24 hours for children with BB <25 kg
- 75 ml / kg BW / 24 hours for children with BB 26-30 kg
- 60 ml / kg BW / 24 hours for children with BB 31-40 kg
- 50 ml / kgweight / 24 hours for children with body weight 41-50 kg
b. Provision of antibiotic drugs in the presence of secondary infection
c. bodyProvision of antipieritics to reduce heat.
d. If there is heavy bleeding then give blood 15 cc / kg body weight / day.
2. Grade III
a. Giving adequate fluids with RL infusion at a dose of 20 ml / kg body weight
/ hour, if there is improvement, continue to give RL 10 m / kg body weight
/ hour, if the pulse and blood pressure are unstable, continue the amount of
fluid based on need within 24 hours minus fluid who have entered.
b. Giving plasma or plasma expanders (dextran L) as much as 10 ml / kg body
weight / hour and can be repeated a maximum of 30 ml / kg body weight
in 24 hours, if after 1 hour of use RL 20 ml / kg body weight / hour the
blood pressure condition is less than 80 mmHg and the pulse is weak, then
 provide adequate fluids in the form of infusion of RL at a dose of 20 ml /
kg body weight / hour if good continue RL as the next calculation.
c. If 1 hour of administration of 10 ml / kg body weight / hour the blood
pressure condition is still decreasing and below 80 mmHg, the patient must
get a plasma container of 10 ml / kg body weight / hour repeated a
maximum of 30 mg / kg body weight / 24 hours if well continue with RL
as the calculation above
3. Degrees IV
a. Provision of adequate fluids by infusion of RL at a dose of 30 ml / kgBW
/ hour, if the blood pressure is good, continue RL as much as 10 ml / kgBW
/ hour.
b. If the blood pressure condition worsens, it must be installed. 2 infusion
channels with the aim of one for RL 10 ml / kgbb / 1 hour and only giving
palasma expanders or dextran L as much as 20 ml / kgBB / hour immersion
1 hour,
c. If the conditions are still too bad, then give plasma expanders 20 ml / kgBB
/ hour,
d. If it continues to deteriorate, then give plasma expanders 10 ml / kg body
weight / hour and repeat a maximum of 30 ml / kg body weight / 24 hours.
e. If after 2 hours of plasma administration and RL does not show
improvement then consult the anesthesiologist for whether or not central
vascular pressure or CVP should be installed. (Hidayat A Aziz Alimul,
2008).

8. COMPLICATIONS OF DHF
1. Shock
In DHF grade IV shock will occur due to loss of fluid through bleeding caused by
intravascular fluid extravasation.
2. Jaundice on the skin and eyes
The presence of bleeding will cause hemolysis in which hemoglobin will be broken
down into bilirubin. Jaundice is caused by a bilirubin deposit.

3. Death
Death is a further complication of DHF in the event of Dengue Shock Syndromee (DSS)
which will result in death.

BASIC CONCEPTS OF NURSING

1. ASSESSMENT
Assessments in patients with Dengue Haemorrhagic Fever according to
Nursalam 2005 are:
a. Biodata / Patient identity
Name, age, sex, address, education, parents 'name, parent's education, and parents'
occupation.
b. The main complaint
The reasons / complaints that stand out in patients with Dengue Hemorrhagic Fever to
come to the Hospital are high heat and weak patients.
c. History of the present disease
Obtained a sudden complaint of heat accompanied by shivering, and when fever
compositional awareness. Heat loss occurs between days 3 and 7 and the patient
is getting weaker. Sometimes accompanied by complaints of colds cough,
swallowing pain, nausea, vomiting, anorexia, diarrhea or constipation,
headaches, muscle and joint pain, heartburn, and the movement of the eyeball
feels sore, as well as manifestation of bleeding in the skin, gums (gums grades
3 and 4), melena, or hematemesis.
d. Past medical history
It is possible that patients who have been reached by DHF can recur DHF again, but
this disease has nothing to do with previous illnesses.
e. Family health history
Areas or places often used as mosquitoes are lack of lighting and sunlight, lots of
standing water, old vases and tires.

f. History of immunization
If the patient has good immunity, the possibility of complications can be avoided.
g. Nutritional history The nutritional
status of patients suffering from Dengue Fever may vary. All patients with good and
bad nutritional status can be at risk if there is a predisposing factor. Patients
suffering from DHF often experience complaints of nausea, vomiting, and
decreased appetite. If this condition continues, and is not accompanied by
adequate nutrition, then the patient may experience weight loss so that the
nutritional status becomes less.
h. Environmental conditions
Often occur in densely populated and less clean environments (such as stagnant water
and clothes hangers in rooms).
i. patterns
- Nutrition and metabolic: frequency, type, abstinence, decreased appetite,
decreased appetite.
- Elimination or defecation. Sometimes patients experience diarrhea or
constipation. While Dengue Hemorrhagic Fever in grade III-IV can occur
melena.
- Elimination of urine or urination needs to be assessed whether often
urinating a little or a lot of pain or not. In Grade IV Dengue Fever hematuria
often occurs.
- Sleep and rest. Patients often experience sleep deprivation due to muscle
and joint pain / pain so that the quantity and quality of sleep and rest are
lacking.
- Cleanliness. Family efforts to maintain personal hygiene and the
environment tend to be lacking, especially to clean the Aedes Aegypti
mosquito breeding grounds.
 - Behavior and response if there is a sick family and an effort to maintain
health.
j. Physical examination includes inspection, palpation, auscultation, and
percussion from head to toe. Based on the level or (grade) of Dengue
Hemorrhagic Fever, the patient's physical condition is as follows:
- Grade I: compositional awareness, general state of weakness, vital signs and
weak pulse.
- Grade II: compositional awareness, general weakness, and spontaneous
petechial bleeding, gum and ear bleeding, and weak, small and irregular
pulse.
- Grade III: apathetic awareness, somnolent, general weakness, weak pulse,
small and irregular, and decreased blood pressure.
- Grade IV: coma awareness, vital signs: pulses are not palpable, blood
pressure is not measured, irregular breathing, cold extremities, sweating,
and skin appears blue.

Examinations include, namely:

- Skin
The presence of petekia on the skin, decreased skin turgor, and appear cold sweat,
and moist. Cyanotic nails or not The
- head and neck The
head feels painful, the face looks red due to fever (flusy), anemic eyes, nose
sometimes experience bleeding (epistaxis) at grade II, III, IV. In the mouth
it is found that the dry oral mucosa, bleeding gums and swallowing pain.
While the throat has pharyngeal hyperemia (in Grade II, III, IV).
- Chest
The shape is symmetrical and sometimes feels tight. In the chest radiograph there
is fluid that is buried in the right lung (pleural effusion), rales (+), Ronchi
(+), which are usually present in grade III and IV
- Abdomen
 Experiencing tenderness, enlarged liver (hepetomegaly), ascites.
- Anus and Genetalia
Can be disturbed due to diarrhea or constipation of the
- Extremities.
Acral cold, and muscle, joint and bone pain occurs.
k. Investigations
On blood tests DHF patients will find:
- Hb and PCV increased (≥20%).
- Thrombocytopenia (≤100,000 / mm3).
- Leukopenia (maybe normal or leukocytosis).
- Ig.D.due positive.
- The results of blood chemistry tests show: hypoprotinemia, hypochloremia,
and hyponatremia.
- Urium and blood pH may increase.
- Metabolic acidosis: pCO <35-40 mmHg HCO3 is low.
- SGOT / SGPT allows increased

2. NURSING DIAGNOSIS THAT MAY APPEAR

1. Ineffective thermoregulation associated with central stimulation of
hypothalamic thermoregulation. The
2. risk of fluid imbalance is evidenced by decreased plasma volume due to
extravascularity of blood plasma.
3. Airway clearance is not effectively associated with airway spasm, foreign
bodies in the airway
4. Acute pain is associated with the pathological process of the disease.
5. Risk of shock evidenced by excessive bleeding, intravascular to the
extravascular fluid displacement
6. Nutrition deficit associated with inadequate nutrition intake due to nausea and
appetite decreased
7. risk of bleeding associated with a decrease in blood clotting factors
(thrombocytopenia)

No. Nursing Diagnosis
1. Fluid Imbalance Risk: Risk After nursing interventions carried out for Management
decreased, increased,
acceleration of displacement of with the result criteria:
fluid from the intravascular,
interstitial or intravascular
Risk Factors
□ procedure is major surgery
□ Trauma /bleeding
□ Burns
□ Aferesis
□ Ascites
□ intestinal obstruction
□ Inflammation pancreas
□ Kidney and gland disease
□ Intestinal dysfunction
Clinical conditions Related to
□ major surgical procedures
Nursing Outcomes Nursing Interventions
(SLKI) (SIKI)
Liquid
or ... x 24 hours the fluid balance increases 1. Observation
□ Monitor hydration status (eg, pulse frequency, pulse strength,
acral, capillary filling, capillary moisture, mucosal humidity,
□ Fluid intake
skin turgor, pressure blood)
□ urine output
□ Daily
□ Mucous membrane balance
□ weight monitor Monitor weight before and after dialysis
□ Food intake
□ Monitor the results of laboratory tests (eg, hematocrit, Na, K,
□ Decreases (1)
Cl, urine specific gravity, BUN)
□ Moderately decreased (2)
□ Monitor hemodynamic status (eg, MAP, CVP, PAP, PCWP if
□ Moderate (3)
available)
□ Moderately increased (4)
2. therapeutic
□ Increased (5)
□ Record intakeoutput and a 24-hour countfluid balance
□ Givefluid intake, as needed
□ Edema
□ Give intravenous fluids, if necessary
□ Dehydration
3. Collaboration
□ AscitesAscites
□ Collaboration diuretics, if necessary
□ Confusion
□ Increased (1)
□ Kidney and gland disease □ Moderately increased (2) fluid Monitoring
□ Bleeding □ Moderately (3) 1. Observation
□ Burns □ Moderately decreased (4) □ Monior frequency and pulse strength
□ Decreased (5) □ Monitor frequency of breath
□ Monitor blood pressure
□ Blood □ Monitor weight
□ pressure Radial pulse □ monitor Capillary filling time
□ pressure average arteries □ monitor Skin turgor elasticity
□ Mucous membranes □ Monitor amount, color and specific gravity of urine
□ Concave eyes □ Monitor albumin and total protein
□ Skin turgor □ levels Monitor serum checks (eg, serum osmolarity, hematocrit,
□ Weight ba and sodium, potassium , BUN)
□ Deteriorate (1) □ Monitor fluid intake and output
□ Moderately worsened (2) □ Identify signs of hypovolemia (eg, increased pulse frequency,
□ Moderate (3) weak palpable pulses, decreased blood pressure, narrowed pulse
□ Moderately improved (4) pressure, decreased skin turgor, dry mucous membrane,
□ Improved (5) decreased urinary volume, increased hematocrit, thirst,
weakness , increased urine concentration, weight loss in a short
time)
 □ Identification of signs of hypervolemia (eg, dyspnea, peripheral
edema, anasarka edema, increased JVP, elevated CVP, positive
hepatojugular reflexes, short weight loss)
□ Identification of risk factors for fluid imbalance (for example,
major surgical procedures, trauma / bleeding, burns, aphesis, int
obstruction estinal inflammation, pancreas inflammation,
kidney and glandular diseases, intestinal dysfunction)
2. Therapeutic
□ Set the monitoring time interval according to the patient's
condition
□ Document the results of monitoring
3. Education
□ Explain the objectives and monitoring procedures
□ Inform the monitoring results, if necessary

2 Hypertherm After nursing care is done for ... x 24 Temperature Regulation

hours. It is expected that ineffective
Definition: Observation
thermoregulation of the patient can be
overcome with the following criteria:  monitor child's body temperature until stable (36.5C -
37.5C)
Failure to maintain body Thermoregulation  Monito the child's body temperature every two hours, if
temperature within the necessary
 Patient does not shiver Patient's
normal range.  Monitor blood pressure, respiratory rate and pulse
 face is not pale
 Monitor color and skin temperature
Causes: Central  Patient is not spasms
 Monitor and record signs and symptoms of hypothermia and
 stimulation of the  No redness of the skin
hyperthermia
hypothalamic □ Increased (1) Increased
 Therapeutic
thermoregulation □ enough (2)
□ Moderately (3)  Attach a continuous temperature monitor, if necessary
 Fluctuations in ambient
□ Decreased (4)  Increase adequate fluid and nutritional intake
temperature
□ Decreased (5)  Adjust the temperature of the environment with patient
 Processes of infertility (eg
infection) needs
 Body temperature normal  Education
 The process of aging
patient Normal
 Dehydration  Explain how to prevent hypothermia due to exposure to cold
 blood pressure
 Symptoms of clothing for air
□ (1)
environmental  Collaboration
□ worsenedmoderately
temperatureclothing
worsened (2)  Collaboration on antipyretics, if necessary.
 Increased oxygen demand
□ (3)
 Changes in metabolic rate
 Extreme environmental □ moderatemoderately Monitoring of Fluid
temperature improved (4) improved
Observation
 Inadequate subcutaneous □ (5)
fat supply  Monitor Nadi, RR and TD

 Extreme body  Monitor Weight

 effects Pharmacological  Monitor elasticity or skin turgor

agents (eg Sedation)  Monitor the number, color and specific gravity
 monior fluid intake and output

Symptoms andSigns Major:  Identification of risk factors for fluid imbalance

Therapeutic
Subjective: -
 Set time interval monitoring in accordance with the patient's
Objective
condition
 Skin cold / warm  Document the results of monitoring
 Shivering  Education
 body temperature
 Explain the purpose and monitoring procedures
fluctuates
 Inform the results of monitoring, if necessary.

Symptoms and Signs Minor

Subjective: -

Objective:

 Piloreksi
 capillary refill> 3 seconds
 Taknan increased blood
 Pale
 Respiratory rate increased
 Tachycardia
 Seizures
 Skin redness
 nail cyanosis

clinical condition related:

□ Injury medulla spinal
□ infection/ sepsis
□ SurgicalAcute
□ brain injury
□ Trauma
3 Nutritional Deficits After intervening during ... x ... .... Nutrition Management
Then the nutrition is fulfilled, with the Observation:
Cause: following criteria:  Identification of nutritional status
• Inability to swallow food Nutritional status of the baby  Identification of allergies and food intolerance
• Inability to digest food • Body weight increases Body  Identification of caloric needs and types of nutrients
• Inability to absorb • length increases  Identify the need for NGT
nutrients □ Decreases (1)  Monitor food intake
• Increased metabolic □ Moderately decreases (2)  Monitor weight
needs □ Moderately (3)  monitoring Monitor results of laboratory tests
• Economic □ increases (4)
• factors Piscological □ Increases (Increases (5)
Therapy:
factors • Yellow skin decreases
• Yellow sclera decreases  Perform oral hygine

Symptoms andSigns • Yellow mucous membrane  Give medication before meals

Major decreases  Facilitation to determine dietary guidelines

Subjective : not available • Pale decreased  Serve foods in an attractive and appropriate temperature

Objective : • Difficulty in eating decreased  Give foods high in fiber to prevent constipationthe
□ Increased (1)  Giveeating high-calorie, high-protein
□ Moderately increased (2)  food supplements if necessary Give
□ Body weight decreases at
least 10% under ideal
range
Minor
Subjective :
□ Fast satiety after eating
□ Cramps / pain absdomen
□ decreased appetite
Objective:
□ bowel sounds hyperactive
□ muscles of mastication
weak
□ muscles to swallow
weakened
□ Membrane pale mucous
□ Thrush
□ Seru, albumin fell
□ Hair loss is excessive
□ Moderately (3)  Stop feeding through NGT when oral intake is tolerated
□ Moderately decreased (4) Education:
□ Decreased (5)  Encourage sitting position, if necessary
• Eating pattern improved  Teach programmed diet
• Thick skin fold improved Collaboration:
• Process of growth and development  Collaboration with nutritionists
improved
• Improved fat layer
□ 1)
□ worsened (Moderately
worsened (2)
□ Moderate (3)
□ (4)
□ ImprovedImproved (5)
□ diarrhea

clinical conditions
associated
□ Stroke
□ Parkinson
□ Mobius syndrome,
□ cerebral palsy
□ Cleft lip
□ Cleft palate
□ Amytropic lateral
sclerosis
□ damages the
neuromuscular
□ burns
□ infections
□ AIDS
□ Disease chorn's
□ Enterocolitis
 □ kinetic Fibrosis
4 of Acute Pain After nursing action ..x .. hours Pain Management
LimitationCharacteristics: expected pain levels to decrease by Observation
 Changes in appetite criteria: □ Identification of location, characteristics, duration,
 Changes in Level Pain frequency, quality, itensity pain
physiological • Complaints Pain □ Identification of pain scale
parameters • grimace □ Identification of nonverbal pain response
 Diaphoresis • Protective attitude □ Identification of factors that aggravate and alleviate pain
Distraction • Restlessness □ Identification of knowledge about pain

 behavior • Difficulty sleeping □ Identification of cultural influences on pain responsepain

 Evidence of pain • Pulling away □ Identification ofeffects i on quality of life

using a standard pain • Focusing on yourself □ Monitor the success of complementary therapies that

checklist for patients • Diaphoresis have been given

who cannot express it • Feelings of depression □ Monitor side effects of analgesic use

 Facial expression (depressed) Therapeutic

• Feelings of fear of experiencing □ Give nonpharmacological techniques to reduce pain (eg.
 behavior Body
tendency to recur TENS, hypnosis, acupressure, music therapy,
attitude protects the
• Anorexia biofeedback, massage therapy, aromatherapy, guided
 Despair
• Perineum feels depressed
 Focus narrows
  Attitude protects the • Uterus palpable rounded imagination techniques, warm / cold compresses, play
area of pain • Tension Muscle therapy).
 Protective behavior • pupils dilatation □ Environmental control that aggravates pain (eg room
 Reports on pain • Vomiting temperature, lighting, noise)
behavior / changes in • Nausea □ Facilitation of rest and sleep
activity □ Increased (1) □ Consider the type and source of pain in the selection of

 PupilDilation □ Moderately increased (2) strategies to relieve pain

 Focusin yourself □ Moderate (3) Education

 Complaints about □ Decreased enough (4) □ Explain the causes, periods and triggers of pain

intensityscale □ Decreased (5) □ Explain strategies to relieve pain

• Pulse frequency □ Suggests to monitor pain independently
 using standard pain
• Breath pattern □ Suggest use analgesics appropriately
 Complaints about
• Blood pressure □ Teach non-pharmacological techniques to reduce pain
pain characteristics
• Thinking process Collaboration
using standard pain
• Focusing □ Collaboration of analgesic administration, if necessary
instruments
• urinary function
Related factors:
• behavior Administration of analgesics
□ Agents of biological
• Appetite Observation
□ injury Agents of
• Sleep pattern
chemical
□ injury Agents of □ Worsens (1)1) □ Identify pain characteristics (eg triggers, relievers,
physical injury □ Moderately worsens (2) quality, location, intensity, frequency, duration) (eg
□ Moderate (3) □ Identification of drug allergy history
□ Moderately improved (4) □ Identification of analgesic type suitabilityeg narcotics,
□ Improved (5) non-narcotics or NSAIDs) with pain severity
Pain Control □ Monitor vital signs before and after administration of
analgesics
• Reporting pain control
□ Monitoranalgesic effectiveness
• Ability to recognize pain onset
therapeutic
• Ability to recognize the cause
□ Discuss the preferred type of analgesic to achieve
of pain
optimal analgesis, if necessary
• Ability to use non-
□ Consider the use of continuous infusions or oploid
pharmacological techniques
boluses to maintain.
• Supporting people nearby
□ Set targets for analgesic effectiveness to optimize patient
□ Decreased (1)
response.
□ Moderately decreased (2)
□ Document responses to analgesic and undesirable
□ Moderate (3)
effects.
□ Sufficiently increased (4)
Education
□ Increased (5)
□ Explain the therapeutic and drug side effects
• Pain complaints
• Analgestic use Collaboration
□ increased (1) □ Collaboration of dosage and type of analgesics,
□ Moderately increased according to indications
(2) Pain Monitoring
□ Moderate (3) Observation
□ Moderately decreased □ Identification precipitating factors and pain reliefpain
(4) □ Monitorquality (eg sharp, blunt, squeezing, overwritten
□ Decreased (5) heavy loads)
□ Monitor location and spread of pain
□ Monitor pain intensity by usingscale
□ MoniorDuration and frequency of pain
Therapeutic
□ Adjust the time interval of monitoring according to the
patient's condition
□ Document monitoring results
Education
□ Explain objectives and monitoring procedures
□ Inform the results of monitoring, if necessary
 5 Risk of shock Risk After being given nursing care during NIC:
... ..x .... hours of shock are not
factors : Shock Prevention
expected with the result criteria:
□ Hypoxemia
□ Monitor vital signs (pulse, blood pressure, RR)
□ Hypoxia NOC:
□ Position the patient to maximize perfusion
□ Hypotension Shock Severity: Anaphylactic
□ Improve the patient's airway if needed
□ Hypovolemia □ There is no drastic decrease in
□ Monitor signs of respiratory failure (PaO2 is low, PaC O2
□ Infection systolic There is no drastic
high)
□ Sepsis □ decrease in diastolicdrastic
□ Collaboration of O2 or ventilation mekais if necessary
□ Systemic □ Noincrease in heart rate
□ Collaboration intravenous fluids
inflammatory □ No arrhythmia
□ Perform ECG in patients
response syndrome □ No additional breath sounds
(SIRS) (wheezing and stridor)
Anaphylaxis Management
□ No dyspnoea
□ edema is reduced / lost □ Collaboration of epinephrine diluted 1: 1000 adjusted for

□ There is a decline of consciousness patient age

□ Monitor tnda signs of shock such as difficulty breathing,

NOC: arrhythmia, seizures, and hypotension

Shock Severity: Cardiogenic

 □ MAP within normal limits (60-
100)
□ There is a decline in systolic blood
pressuredrastically
□ decreasedphoto diastolic pressure
drastically
□ CRT <3 seconds
□ No increased heart rate drastically
□ Nadi palpable strong
□ reduced chest pain
□ No drastic increase in RR
□ No cyanosis
□ PO2 and PCO2 levels within
normal limits
□ Collaboration spasmolytic administration, antihistamines or
corticosteroids if there is an allergic reaction (urticaria,
angioedema or bronchospasm)
Cardiac care
□ Cardiovascular status
□ monitor Respiratory monitor for signs of symptoms of heart
failure
□ Evaluate the incidence of chest pain before hospitalization
□ Perform a comprehensive assessment of peripheral
circulationcardiac
□ Monitorresults e.g. electrolyte)
Bleeding reduction,
□ identification of the cause of bleeding
□ Monitor the amount of bleeding

NOC: □ Monitor hematocrit levels

Shock Severity: Hypopholemic □ Collaboration of blood transfusion

□ MAP within normal limits (60-

100)
□ No drastic decrease in systolic
pressuredrastically
□ Nodecreased diastolic pressure
□ No there is a drastic increase in
heart rate
□ CR T <3 seconds
□ Strong palpable pulse
□ No drastic increase in RR
□ No cyanosis
□ PO2 and PCO2 levels within
normal limits
□ Hematocrit within normal limits
□ No decreased consciousness
NOC:
Shock Severity: Neurogenic
□ There is no drastic decrease in
systolic pressure
□ No decrease in diastolic pressure
drastically
 □ strong pulse
□ There is no drastic change in RR
□ PO2 and PCO2 levels within
normal limits
□ No decrease in consciousness
□ No decrease in body temperature
NOC:
Shock Severity: Septic
□ No drastic decrease in systolic
pressuredrastically
□ Nodecreased diastolic pressure
□ strong pulse
□ Nothere is a drastic increase in RR
□ No decrease in consciousness
□ No drastic changes in body
temperature
6 The risk of bleeding after nursing is done .. x .. hours Prevention of Bleeding
risk factors expected bleeding to decrease with the Observation
• aneurysm following criteria:  Monitor signs and symptoms of hemorrhage
• Gastrointestinal disorders  monitor hematocrit / hemm values oglobin before and after
• Impaired liver function Bleeding Rate blood loss
• Complications of • Moisture of the mucous  monitor orthostatic vital signs
pregnancy membrane Therapeutic
• complications post- • Skin Moisture  Maintain bed rest during bleeding
partum □ Decreased (1)  Limit infasive measures, if necessary
• Disorders of coagulation □ Decreased enough (2) Educate
(eg, thrombocytopenia) □ Moderately (3)  Explain signs and symptoms of bleeding
• The effects of □ Moderately increased (4)  Advise using socks during ambulances
pharmacological agents □ Increased (5)  Recommend increase food intake
• Surgery • Hemoptysis Collaboration
• Trauma • Hematemesis
 Bleeding control medications, if necessary
• less exposed to • Hematuria
 collaboration administrationblood products
information about □ Increased(1)
 Collaborative softener cleaning, if necessary
Prevention of bleeding □ Moderately increased (2)
• Malignancy □ Moderate (3)
□ Moderately decreased (4)
□ Decreased (5)
• Hemoglobin
 • Hematocrit
• Body temperature
□ Worsen (1)
□ Moderately worsened (2)
□ Moderately (3)
□ Moderately improved (4)
□ Improved (5)
7 Ineffective airway clearance After intervention during ... x ... .... SIKI: Airway management
Expected increased airway clearance, Action Measures
Cause: with the following criteria:: Observation:
Physiological IDHSAirway clearance  Monitor vital signs
□ airway spasm □ Able to cough effectively  Monitor breath pattern
□ Hypersecretion of the □ Sputum production decreased  Monitor Monitor breath sounds
airway Decreased  Monitor sputum (amount, color, aroma)
□ Neuromuscular □ wheezing decreased Therapy:
dysfunction □ Dyspnea decreased  Maintain patency of the airway with headtilt and chinlift
□ Foreign body in the □ anxiety (jaw thrust if suspicious cervical trauma) cervical trauma
airway □ Increased breathing frequency  Position comfortable semi-fowler or fowler
□ improved  Give warm drink
 □ Presence of an artificial  Perform chest physiotherapy, if necessary
airway  Perform mucus suction less than15 seconds
□ Retained secretions  Perform hyperoxygenation before suctioning
□ Hyperplasia of the endotracheal
airway wall  Remove solid blockage with forceps McGill
□ Infection process  Give oxygen, if necessary
□ Allergic response Education:
□ Effect pharmacological  Advise fluid intake of 2000 ml / day, if not
agents (eg . Anesthesia) contraindicated
Situational  Teach effective coughing techniques
□ Active
Collaboration:
□ smoking Passive
 Collaboration of bronchodilators, expectorants,
smoking
mucolites, if necessary
□ Exposed to pollutants
Symptoms and Signs
Major
Subjective : not available
Objective :
□ Ineffective
□ cough Unable to
coughsputum
□ Excessive
□ Wheezing, wheezing and /
or dry crackles
□ Mekonium in the airway
(in neonates)
Minor
Subjective :
□ Dyspnea
□ Difficult to speak
□ Orthopnea
Objective :
□ Restless
□ Cyanosis
□ Decreased naps
Decreased
□ breathing frequency
Changed breathing
 □ pattern
Clinical conditions related
to
□ Gullian barre syndrome
□ Ultiple sclerosis
□ Myastenia gravis
□ Diagnostic procedure
□ Central nervous system
depression
□ Head injury
□ Stroke
□ Quadruplegia
□ Aspiration meconium
aspiration syndrome
□ Respiratory tract
infections
8 Nausea After nursing interventions are carried outManagement of nausea
Cause of for 3 x 24 hours it is expected that theObservation
• Disturbances uan digestive □ Identification of factors causing nausea
system
 Symptoms and Signs Major
Subjective:
• Complaining nausea
• Feeling want to vomit
• Not intending to eat
Objectively (not available)
Symptoms and Signs Minor
Subjective
□ Feeling acid in the mouth
□ Often swallowing
Objective
□ Saliva increases
□ Pale
nausea level decreases with outcome Therapeutic
criteria:
□ Give small and frequent portions of food
Educate
Nausea level □ Suggest a break and enough sleep
Collaboration
• Appetite increased from scale 2 to
5 □ Collaboration of antiemetic
• Nausea complaints decreased
from scale 3 to 5
• Feelings of vomiting decreased
from scale 3 to 5
 NURSING REPORT ON PATIENTS Mrs. SC
WITH DHF IN ROYAL PRINCE ROOM
DATE 14-17 OCTOBER 2019

I. Client Self Identity

Name : Mrs. SC Hospital Entrance Date: 13-10-19

Place / Date of Birth : Denpasar, 1-1-2001 Source of Information : Patient

Age : 18 Years of Religion : Muslim

Gender : Female Marital Status : Single

Education : High School Suku : Java

Occupation : Student OldWorking :-

Address : Jl. Teuku Umar No. 108 Denpasar

MAIN COMPLAINT : Fever goes up and down

DISEASE HISTORY : the patient says the first time a fever is felt 3 days SMRS
(9-10-19) accompanied by a feeling of pain in the joints,
headaches, nausea and vomiting. The patient said that he had
been taking a fever-lowering medication, but complaints of
fever were still felt up and down. Sunday, 12-10-19 patients
said they had nosebleeds 2 times in the morning and at night.
After deciding to see a doctor and advised to check the lab.
From the results of the laboratory examination on Saturday,
12-10-19, the results were obtained:

- Dengue NS1 Positive antigen

- PLT: 206 x 103/ µL

- HCT: 39.7%

- HGB: 14.2 g / dL

From the patient's doctor was given antibiotic therapy, fever

and anti nausea. Sunday, 13-10-19 at 02.30 WITA, the
patient's family decided to take the patient to IGD Bros for
an examination because the patient complained of weakness.

In the emergency room at BROS General Hospital,

laboratory tests were performed again, namely complete
blood tests and anti-Salmonella anti-IgM tests. From these
tests the results obtained:

- Anti IgM Salmonella: negative

- WBC : 2.64 x 103/ µL

- PLT : 114 x 103/ µL

- HCT : 41.2%

- HGB : 14.2 g / dL

Therapy obtained in the ED is:

- IVFD RL loading 1 flash (500 ml), continued 30

- tpm Sanmol drip 1 gr

- Pumpicel 40 mg IV / set
Based on the results of physical and lab examination, the
patient was finally admitted to the Royal Prince room 105,
Sunday, 13-10-19.
1. The closest family that can be contacted (parents, guardians, husband, wife, etc.)
Occupation : Private Education : S1

Address : Jl. Teuku Umar No. 108 Denpasar

2. Allergies:

Type Reaction Measures

truism truism truism

3. Habits: smoke / coffee / drug / alcohol / other

4. drugs:

Duration: 1 day

Alone: denying

Others (recipe):fever, anti-nausea, and antibiotics

5. Pattern nutrition :

Frequency / portion of food: 3 times x / day, finished ¼ - ½ portion

Weight : 56 kg Height: 167 cm

Type of food : Rice, side dishes, vegetables

Preferred food: fast foodfood

Disliked: kale and vanilla vegetables Restricted

food : refuted

Appetite : [] good
 [] moderate, reason : nausea / vomiting /
thrush / etc [√] less, reason : nausea /
vomiting /thrush / etc

BB change in the last 3 months: refuted

6. Pattern of elimination :

a. Defecation

Frequency: 1x / day Time : morning /afternoon /

evening / night Color: yellow Consistency : flabby

Laxative use: refuted

b. Urination

Frequency: 8-10 / day Color : clear yellow

Odor : distinctive urine

7. Sleep and rest patterns:

Sleep time (hours) : 11.00-13.00 WITA, night: 22.00-05.00 WITA

Length of sleep / day : 8-9 j am / day

Sleep habits : no

Sleep habits : poor lighting

Difficulty in sleeping : [] before going to sleep

[] frequent / easily awakened

[] feeling dissatisfied after waking up

8. Activity and exercise patterns:

a. Activities on the job : During MRS the patient is absent from lectures
 b. Sports :-

c. Leisure activities : resting / watching TV

d. Difficulties / complaints in this regard: [] body movements [] preening

[v] bathing, expressing [] easy to feel tired

[] wearing clothes [] shortness of breath after holding activities

9. Work patterns:

a. Occupation :student 1 year old

b. Number of hours worked : 4-8 hours

c. Work schedule : 5 working days

II. Family history

Genogram:
III. Environmental history Environmental

hygiene: clean

Danger : refuted

Pollution : vehicles, far from the factory

IV. Psychosocial aspects

1. Mindset and perception

a. Tools used:

[] glasses [] hearing aids [] hearing aids

b. Difficulties that are

experienced: [v] often
 dizzy
[] decreased sensitivity to heat and cold []
reading / writing

2. Self-perception

Current thought : tasks to change lecture hours

Expectations after undergoing treatment : always healthy

Changes felt after illness :: lazy activity

3. mood: not sad

4. Relations / communication:

a. Talk

[v] clearlylanguage: the main Indonesia

[v] of relevant regional languages:Java

[v] able to express

[v] able to understand others

b. residence [v]
own
[] with others, that is ...................................

c. Family life

- customs that are adhered to : do not conflict with

health

- making family decisions : parents

- pattern ko communication : effective

- financial : [v] adequate [] less

 d. Difficulties in the family

[] relationships with parents

[] relationships with relatives []

relationships with husband / wife

5. Sexual habits Sexual

a. disorders due to the following conditions: [] fertility []

menstruation
[] libido [] pregnancy

[] erection [] contraception
 b. Understanding of function sexual :

Understanding and understanding how to care for and maintain cleanliness

6. Coping Defense

a. Decision making []
alone
[v] assisted by others; specify the parents and sister

b. Preferably about yourself: Clever and

beautiful

c. thing to be changed from

life:

None

d. What to do when you're stressed:

[v] Troubleshooting [] looking for help

[] eat [] taking medication

[] sleep

[] Other -Other (for example angry, silent etc.) specify

........................................ ............

7. the value system - confidence

a. who or what is the source of

strength:

Family

b. Is God, Religion, Faith is important to you: [v] yes [] no

 c. activities conducted on Religion or belief (wide and frequency) Mention:
prayer 5 times

d. Religion or Belief Activities you want to do while in hospital, Mention: pray in

your heart

V. Physical Assessment

A. Vital Sign
Blood pressure: 100/60 mmHg

Temperature : 38.2 0C

Pulse : 92 x / minute

Breathing : 20 x / minute

B. Awareness : Compost mentis GCS : 15

Eye :4

Motor : 5

Verbal:: 6

C. State general:
▪ aches / pains : 1. mild 2. moderate 3. severe
Pain scale :2

Pain in the area : head

▪ Nutritional status : 1. fat 2. normal 3. thin

BB : ………… .. TB: ………… ...
 ▪ Attitudes : 1. calm 2. restless 3. hold pain

▪ Personal hygiene : 1. clean 2. dirty 3. others …….

▪ Time / place / person orientation: 1. good 2. disturbed ……

D. Physical examination Head to

1. Head
▪ shape toe: 1. mesochepale 2. microchepale
3. hidrochepale 4. others ……………

▪ Lesions / wounds : 1. hematoma 2. bleeding 3.tear sores

4. other………….

2. Hair
▪ Color : brownish black
▪ Abnormalities: loss / etc ………….

3. Eyes of
▪ Vision : 1. normal 2. glasses / lenses 3. others …….

▪ Sclera : 1. jaundice 2. no jaundice

▪ Conjunctiva : 1. anemic 2. no anemic

▪ Pupil : 1. isokoranisokor 2.3. mydriasis 4. cataract

 ▪ Abnormalities : childhood / left blindness ……….

▪ Additional data …………….

4. Nose
▪ smell: 1. normal 2. No interference ............

▪ discharge / blood / polyps (-)

▪ Pull the nose hat: 1. Yes 2. No

5. Ear

▪ Hearing: 1. normal 2.damage 3. deafright /

left

4. tinnitus 5. hearing aids 6. other

▪ Skret / fluid / blood : 1. there/ no 2. smell …… .. 3. color ………

6. mouth and teeth

▪ lips : 1. moist 2. dry 3. cianosis 4 Broken

▪ mouth and throat: 1. normal 2. lesions 3.stomatitis

▪ tooth : 1. full / normal 2. toothless 3. others ……… ..

 7.neck

▪ thyroid : 1. yes 2. no
enlargement
▪ lesions : 1. no 2. yes, next to .......

▪ Carotid pulse : 1. 2. no
palpable

▪ Lymphoid : 1. yes 2. no
enlargement
8. Thorax

▪ Heart : 1. pulse 92 x / min, 2. strength: strong/ weak

3. rhythm: regular/ not 4. others …………….

▪ Lung : 1. breath frequency : regular/ not

2. quality : normal/ deep / shallow
3. breath sounds : vesicular/ ronchi / wheezing
4. cough : yes / no
5. airway obstruction: sputum / mucus / blood / saliva

▪ Chest retraction: 1. nono 2.2. no No

9.
▪ intestinal peristalsis Abdomen: 1. No, 10 x / min
2. no
3. Hiperperistaltik 4. others ...

▪ Bloating: 1. yes 2. No
▪ Tenderness: 1. No 2. yes quadrant ...... ../ part….
 ▪ Ascites : 1. No
10. Pimotic
▪ Genetalia : Yes1. Yes 2.2. No
▪ Aid : 1. Yes 2. No
▪ abnormalities : 1. No 2. Yes, in the form of …………

11. skin
▪ Turgor : 1. elastic 2. dry 3. others
▪ Laseration : 1. wound 2. bruising 3.
others in the area ………… ..
▪ Skin color : 1. normal (white / brown / black)
2 pale 3. cianosis 4. jaundice 5. other-

Other: there are red spots on the upper inner arm, back,
and some biktik reddish spots in the lower limb

12. extremity

▪ muscle strength:

▪ ROM : 1. full 2. limited

▪ Hemiplegi / parese: 1. no 2. yes, right / left

▪ Akral : 1. warm 2. cold

▪ Capillary refill time : 1. <3 seconds 2.> 3 seconds

▪ Edema: 1. no 2. in the area ………….

 ▪ Other: .................. ..

13. Data neurological examination

Stiff neck(-)

pathological reflexes (-)

physiological reflexes (+)

VI. Data Supporting

a. Investigations
- Anti Denge Inspectiondate 12-10-19
- InspectionDL dated 13-10 -19 at 07.00 WITA (results attached)

b. Therapy Program
- Sanmoldrip 1 gr IV k / p (if fever> 37.8)
- Gastrofer 1x40 mg IV
- Narfos 3x4mg IV
- IVFD RL 30 tpm
VI. NURSING PLAN
NO. NURSINGNURSING DIAGNOSESOUTSIDE NURSING PLAN

1 Hyperthermia After nursing care done for 3 x 24 hours. It is Temperature Regulation

expected that hyperthermia can be overcome by
Definition : Observation
the results of the following criteria:
Failure to maintain body temperature  Monitor child's body temperature until stable
Thermoregulation
within the normal range. (36.5C - 37.5C)
 Patient does not shiver Patient's  Monito child's body temperature every two
Causes: Central
 face is not pale hours, if necessary
 stimulation of the hypothalamic  Patient is not spasms  Monitor blood pressure, respiratory rate and
thermoregulation  No redness of the skin pulse
 Fluctuations in ambient temperature □ Increases (1)  Monitor color and skin temperature
 Processes of infertility (eg infection) □ Moderately increases (2)  Monitor and record signs and symptoms of
 The process of aging □ Moderately (3) hypothermia and hyperthermia
 Dehydration □ Moderately decreases (4) Therapeutic
 Symptoms of clothing for □ Declines (5)
 Attach a continuous temperature monitor, if
environmental temperatureclothing
necessary
 Increased oxygen demand  Body temperature of the patient is
 Increase adequate fluid and nutritional intake
 Changes in metabolic rate normal
 Adjust the ambient temperature to the patient's
 Extreme environmental temperature  Pressure normal blood
needs
 Inadequate subcutaneous fat supply □ Worsen (1)
Education
 Extreme body □ Moderately worsened (2)
□ Moderate (3)
 effects Pharmacological agents (eg □ Moderately improved (4)  Explain how to prevent hypothermia due to
Sedation) □ Improved (5) exposure to cold air
Collaboration
Symptoms andSigns Major:
 Collaboration on antipyretics, if necessary.
Subjective: -
Monitoring of Fluid
Objective
Observation
 Skin cold / warm
 Shivering  Monitor Nadi, RR and TD
 body temperature fluctuates  Monitor Weight
 Monitor elasticity or skin turgor
Symptoms and Signs Minor  Monitor the number, color and specific gravity
 monior fluid intake and output
Subjective: -
 Identification of risk factors for fluid imbalance
Objective:
Therapeutic
 Piloreksi
 Set time interval monitoring in accordance with
 capillary refill> 3 seconds the patient's condition
 Taknan increased blood  Document the results of monitoring
 Pale Education
 Respiratory rate increased
 Explain the purpose and monitoring procedures
 Tachycardia
 Inform the results of monitoring, if necessary.
 Seizures
  Skin redness
 nail cyanosis

clinical condition related:

□ Injury medulla spinal
□ infection/ sepsis
□ SurgicalAcute
□ brain injury
□ Trauma
2 Nausea
Causes
• of Digestive System Disorders
Symptoms and Major Signs
Subjective:
• Complaining nausea
• Feeling want to vomit
• Not intending to eat
Objectively (not available)
Symptoms and Signs Minor
Subjective
□ Feeling acid in the mouth
□ Often swallowing
After nursing interventions for 3 x 24 hours are Management of nausea
expected the rate of nausea decreases with the Observation
following criteria: □ Identification of factors causing nausea
Therapeutic
□ Give small and frequent portions of food
nausea rate
Education
• Appetite increases from a scale of 2 to
□ Encourage adequate rest and sleep
5
Collaboration
• Nausea complaints decreases from a
scale of 3 to 5 □ Collaboration with antiemetics
• Feelings of vomiting decreases from a
scale of 3 to 5
Objectively
□ Saliva increases
□ Pale

3 Risk of shock Risk After being given nursing care for 3 x 24 hours NIC:
no shock is expected with the result criteria:
factors : Shock Prevention
□ Hypoxemia NOC:
□ Monit or vital signs (pulse, blood pressure, RR)
□ Hypoxia Shock Severity: Anaphylactic
□ Position the patient to maximize perfusion
□ Hypotension □ No drastic decrease in systolic
□ Improve the patient's airway if needed
□ Hypovolemia □ No there is a drastic decrease in
□ Monitor for signs of respiratory failure (low PaO2,
□ Infection diastolicdramatic
high PaCO2)
□ Sepsis □ Noincrease in heart rate
□ Collaboration of O2 administration or ventilation
□ Systemic inflammatory response □ No arrhythmia
of mechaens if needed
syndrome (SIRS) □ No additional breath sounds (wheezing and
□ Collaboration of intravenous fluids
stridor)
□ Perform ECG examination in patients with
□ No dyspnoea
□ Reduced / diminished edema
Anaphylaxis Management
□ No decrease in consciousness
□ Collaboration of diluted epinephrine 1: 1000 is

NOC: adjusted for the patient's age

Shock Severity: Cardiogenic □ Monitor for signs of shock such as difficulty
□ MAP within normal limits (60-100 ) breathing, arrhythmia, seizures, and hypotension
□ No drastic decrease in systolic □ Collaborative administration of spasmolytic, anti-
pressuredrastically histamine or corticosteroids if there is an allergic
□ Noreduced diastolic pressure reaction (urticaria, angioedema, or bronchospasm)
□ CRT <3 seconds Cardiac care
□ No drastic increase in heart rate
□ Monitor cardiovascular status
□ Strong palpable pulse
□ Respiratory monitor for symptoms of heart failure
□ Reduced chest pain
□ Evaluate the incidence of chest pain before
□ No drastic increase in RR
hospitalization
□ No cyanosis No
□ Perform a comprehensive assessment of the
□ PO2 and PCO2 levels within normallimits
peripheral circulation
□ Monitor laboratory results (eg. electrolyte)
NOC:
Bleeding reduction,
Shock Severity: Hypopholemic
□ MAP d at normal limits (60-100) □ identification of the cause of bleeding
□ No drastic decrease in systolic □ Monitor the amount of bleeding
pressuredrastically □ Monitor hematocrit levels
□ Nodecreased diastolic pressuredramatic □ Collaboration of blood transfusion
□ Noincrease in heart rate
□ CRT <3 seconds
□ Strong palpable pulse
□ No drastic increase in RR
□ No cyanosis No
□ PO2 and PCO2 levels in normal limit
□ Hematocrit within normal limits
□ No decrease in consciousness
NOC:
Shock Severity: Neurogenic
□ No drastic decrease in systolic pressure
□ No decrease in diastolic pressure
drastically
□ strong palpable pulses
□ No drastic change in RR No
□ PO2 and PCO2 levels within normal limits
□ No decrease in consciousness
□ No decrease in body temperature
NOC:
Shock Severity: Septic
□ No decrease in systolic pressure drastically
□ No decrease in diastolic pressure
dramatically
□ Strong palpable pulse
□ No drastic increase in RR
□ No decrease in consciousness
□ No drastic change in body temperature
4 The risk of bleeding After nursing action 3 x 24 hours are expected Prevent bleeding
risk factors bleeding decreases with the following criteria: Observation
• aneurysm  Monitor signs and symptoms of bleeding
• Gastrointestinal disorders level of bleeding  monitor hematocrit / hem values moglobin before
• Impaired liver function • humidity mucous membranes and after blood loss
• Complications of pregnancy • Moisture skin  monitor orthostatic vital signs
• complications post-partum □ Descending (1) Therapeutic
□ Self-mennurun (2) 
• Disorders of coagulation (eg, Maintain bed rest during bleeding
□ Average (3)  Limit infasive measures, if necessary
thrombocytopenia)
□ Self-rising (4)
• The effects of pharmacological Educate
□ increase (5)  Explain the signs and symptoms of bleeding
agents
• hemoptysis 
• Surgery Advise using socks during ambulances
• Haematemesis
• Trauma  Advise increase food intake
• haematuria
• less exposed to information about Collaboration
□ Increase (1)
prevention of bleeding  bleeding control drugs, if necessary
□ Moderately increase (2)
• process of malignancy  collaboration administrationblood products
□ Moderate (3)
 Collaborative softener cleaning, if necessary
□ Decrease enough (4)
□ Decrease (5)
• Hemoglobin
• Hematocrit
• Body temperature
□ deteriorate (1)
□ Moderately deteriorate (2)
□ Moderate (3)
□ Moderately improve (4)
□ Improve (5)
II. DATA ANALYSIS
DATE / INTERPRETATION / OF
NO DATA FOCUS
HOUR CAUSE PROBLEMS
1 Monday, DS: - DHF Hyperthermia
10/14/2019 DO:
At 09:40 ▪ Axilla Viremia
WITA temperature:
38.20C
▪ 92x pulse / Stimulation of macrophage cells
minute producing pyrogen endogenous
▪ Warm
palpable
Entering the hypothalamus
skin

Disrupting thermoregulation

2 At 09:45 AM DS: DHF Dengue Nausea

▪ Patient
complains of virus in blood circulation
nausea and
wants to Body response forms antibody
vomit
▪ Patient says Affected organ (one of which is
no intention digestion) )
to eat
▪ Patient
complains of
acid in
mouth
DO:
▪ Px appears
pale
3 at 09.50 DS: - DHF risk
WITA DO:
 ▪ TD: 100/60 Increased membrane
mmHg Axilla permebilityShock
▪ temperature:
38.20C Platelet aggregation
▪ Pulse 92x /
minute Thrombocytopenia
▪ RR: 20x /
minute Bleeding
▪ PLT (13-10-
19, 07.00 Ineffective tissue perfusion
WITA): 52 x
103/ µL
▪ HCT: 38.1%
▪ HGB: 13.2 g
/ dL
4 At 10:00 DS: - DHF Risk of
WITA DO: bleeding
▪ PLT (13-10- Activation of thecomplement
19, at 7:00 system
a.m. WITA):
52 x 103/ µL PermebelIncreased
▪ HCT: 38.1%
▪ HGB: 13.2 g platelet
/ dL aggregationthrombocytopenia

Platelet
III. NURSING DIAGNOSIS BASED ON PRIORITY
DATE
NO NURSING DIAGNOSIS
APPEARS
1 Monday, HyperthermiaHyperthermia associated with the disease process
10/14/2019 (DHF) is characterized byassociated with the disease process (DHF)
At 09.40 is characterized by axilla temperature: 38.214:40axilla temperature:
WITAAM 38.200C, pulse 92x / minute, warm palpable skinC, pulse 92x /
WITA minute, warm palpable skin
2 Monday,10/1 Nausea associated with digestive system ganggaun marked by
4/2019 patients complaining of nausea and vomiting, the patient said he did
At 09.45 not intend to eat, the patient complained of acid in the mouth, the
WITA patient looked pale

3 Monday, Risk shock as evidenced by hypotension (TD: 100/60 mmHg)

10/14/2019
At 09.50
WITA
4 Monday, risk of bleeding is evidenced by thrombocytopenia (PLT (13-10-
10/14/2019 19, 07.00 WITA): 52 x 103/ µL)
At 10:00
WITA The
V. NOTE NURSING / IMPLEMENTATION

N NO. NAME /
DATES HOURS IMPLEMENTATION EVALUATION
O DX TTD
At 11.00 1. Monitor patient's vital signs S: Patient complains feeling weak
1,2,3,
WITA O:
4
TD: 100/60 mmHg
N: 94 x / minute
S: 38.10C
RR: 20 x / minute
Pain scale 2/10
1 At 11:10 2. Take delegative action to give 1 gram of S: patient and say understand the
Monday, WITA drip sanmol function and purpose of
1
14-10-19 givingdrug
O: 1 gram drip sanmol attached to
route IV, signs of allergy (-)
3.4 At 13.00 3. Monitor the results of laboratory tests S: -
WITA O:
▪ WBC: 5.43 x 103/ µL
▪ PLT: 33 x 103/ µL
▪ HCT: 36.5%
▪ HGB: 12.8 g / dL
 3 At 13.10 4. Monitor for signs of shock S: patient says do not feel
WITA difficulty breathing
O:
▪ RR: 20x / minute
▪ Seizures (-)
▪ Arrhythmia (-), N: 88x /
minute, palpable
▪ Conscious level: Compos
mestis
▪ Hypotension (-), BP: 115/71
mmHg
1,3,4 o'clock 5. Monitor intake and output S: Patients say since 06.00 WITA
13.20 have been drinking water 4 times
WITA (glass volume 100 ml) 400 ml,
urinating 3 times (volume: 650
ml), vomiting 4 times
O: IVFD RL 30 tpm macro
CM through IV: 600 ml
2 Tuesday, 1,2,3, At 11.00 1. Monitoring the patient's vital signs S: The patient complains feeling
4
15-10-19 WITA weak
O:
TD: 108/65 mmHg
N: 84 x / minute
 S: 37,00C
RR: 20 x / minute
Pain scale 2/10
3.4 At 12.00 2. Monitor results of laboratory tests S: -
WITA O:
▪ WBC: 4.51 x 103/ µL
▪ PLT: 28 x 103/ µL
▪ HCT: 41.5 %
▪ HGB: 14.3 g / dL
3 At 13.00 3. Monitor for signs of shock S: patient says he has no difficulty
WITA breathing
O:
▪ RR: 20x / minute
▪ Seizures (-)
▪ Arrhythmia (-), N: 87x /
minute, palpable
▪ The level of awareness:
Compos mestis
▪ Hypotension (-), BP: 112/68
mmHg
1,3,4 at 13:10 4. Monitor intake and output S:Patients say since 06.00 pm
pm already drink water as much as
 300 ml, piss 2 times (volume: 400
ml), vomiting 2 times
O: IVFD RL 30 tpm macro
CM through IV: 500 ml
3 Wednesday 1,2,3, At 16.00 1. Monitor the patient's vital signs S: The patient says dizziness and
4
, 16-10-19 WITA nausea reduced
O:
TD: 117/64 mmHg
N: 91 x / minute
S: 36.60C
RR: 20 x / minute
Pain scale 1/10
2 At 19.00 2. Take a delegative action on antiemetic S: Patients and families say they
WITA understand the function and
purpose of drug
O: Narfos 8 mg given route IV,
allergic reaction (-)
3.4 At 19.30 3. Monitoring the results of laboratory tests S: -
WITA O:
▪ WBC: 6.97 x 103/ µL
▪ PLT: 52 x 103/ µL
▪ HCT: 41.5%
▪ HGB: 14.2 g / dL
 3 At 20.00 4. Monitor for signs of shock S: patient says he has no difficulty
WITA breathing
O:
▪ RR: 20x / minute
▪ Seizure (-)
▪ Arrhythmia (-), N: 82x /
minute, palpable
▪ Conscious level: Compos
mestis
▪ Hypotension (-), TD: 115/72
mmHg
1,3,4 At 21.00 5. Monitor intake and output S: The patient said that since 12.00
WITA WITA he had drunk 700 ml of
water, urinated 4 times (volume:
650 ml), vomiting 2 times
O: IVFD RL 30 tpm macro
CM through IV: 800 ml
4 Thursday, At 11.00 1. Monitor the patient's vital signs S: The patient says he still feels a
1,2,3,
17-10-19 WITA bit of nausea, but the patient said
4
there was no vomiting
O:
TD: 122/76 mmHg
N: 78 x / min
 S: 36.40C
RR: 20 x / min
Pain scale 0/10
3.4 At 13.00 2. Monitor the results of laboratory tests S: -
WITA O:
▪ WBC: 8.60 x 103/ µL
▪ PLT: 104 x 103/ µL
▪ HCT: 38.2%
▪ HGB: 13.0 g / dL
3 At 13.10 3. Monitor signs of shock S: patient says no difficulty
WITA breathing
O:
▪ RR: 20x / minute
▪ Seizures (-)
▪ Arrhythmia (-), N: 76x /
minute, palpable
▪ Conscious level: Compost
mestis
▪ Hypotension (-), TD: 118 / 72
mmHg
1,3,4 At 13.20 4. Monitor intake and output S: The patient said that since 06.00
WITA WITA he has drunk 400 ml of
 water, urinated 3 times (volume:
600 ml), vomited (-)
O: IVFD RL 30 tpm macro
CM through IV: 500 ml
VI. EVALUATION
N NAME /
DATE DIAGNOSIS NURSING EVALUATION
O TTD
1 Thursday, Hyperthermia associated with S : The
17-10-19 the disease process (DHF) is ▪ patient said tiding felt fever
At 14.00 characterized by axilla O : The
WITA temperature: 38.20C, pulse 92x / ▪ patient did not look shivering, pale (-), convulsions (-), reddish
minute, warm palpable skin skin (-),
▪ TD: 76x / minute
▪ N: 118/72 mmHg
▪ S: 36.40C
▪ RR: 20x / minute
▪ Scal a Pain: 0/10
A : The aim of the problem is resolved
P :
▪ Maintain the patient's condition
▪ Monitor vital signs
▪ Take a delegative action of antipyretics when the
temperature is> 37.5°C

2 At 14:10 Nausea associated with ganggaun
pm digestive system characterized by
the patient complains of nausea
and want to vomit, the patient
says no intention of eating, the
patient complained of acid in the
mouth, the patient was pale
I : Monitor TTV
E : The
▪ patient says tiding feels fever The
▪ patient does not look shivering , pale (-), seizures (-), reddish
skin (-),
▪ BP: 74x / min
▪ N: 120/72 mmHg
▪ S: 36.40C
▪ RR: 20x / min
▪ Pain Scale: 0/10
R : Objective achieved the problem is resolved
S:
▪ Patients say they feel a bit queasy
▪ appetite has increased
▪ Patients say being able to spend ¾ portion of food provided
O :
▪ Vomiting (-)
▪ Portion of food left over ¼ part
A : The goal of the problem is resolved
P :
▪ Maintain the condition of the patient
▪ Monitor the feeling of nausea and acid in the mouth
I : Monitor feelings of nausea and acid in the mouth
 E : The
▪ patient says not feeling nauseous
▪ Sour taste in mouth (-)
▪ Appetite has increased
▪ Patients say they are able to spend ¾-1 portion of food
provided
▪ Vomiting (-)
R : Goal is reached, problem is resolved
3 At 14.20 risk is evidenced by hypotension (TD: S: The patient said he had no difficulty breathing
WITA 100/60 mmHg) O:
Shock ▪ RR: 20x / min
▪ Seizures (-)
▪ arrhythmias (-), N: 76x / minute, strong palpable
▪ level of awareness : Compost mestis
▪ Hypotension (-), TD: 120/72 mmHg
▪ WBC: 8.60 x 103/ µL
▪ PLT: 104 x 103/ µL
▪ HCT: 36.4%
▪ HGB: 13.0 g / dL
A : Shock does not occur
P :
▪ Maintain patient condition
▪ Monitor for signs of shock

4 At 14.30 Risk bleeding is evidenced by
WITA thrombocytopenia (PLT (13-10-
19, at 07.00 WITA): 52 x 103/
µL)
▪ TTV Monitor
I :
▪ Monitor for signs of shock
▪ Monitor for TTV
E :
▪ RR: 20x / minute
▪ Seizures (-)
▪ Arrhythmia (-), N: 76x / minute, palpable
▪ Conscious level: Compost must be
▪ hypotension (-), TD: 120/70 mmHg
▪ WBC: 8.60 x 103/ µL
▪ PLT: 104 x 103/ µL
▪ HCT: 36.4%
▪ HGB: 13.0 g / dL
R : Shock does not occur
S : (-)
O :
▪ Mucous lips appear moist, elastic skin
▪ TD: 76x / minute
▪ N: 120/70 mmHg
▪ S: 36.40C
▪ RR: 20x / minute
▪ Pain Scale: 0/10
 ▪ WBC: 8.60 x 103/ µL
▪ PLT: 104 x 103/ µL
▪ HCT: 36.4%
▪ HGB: 13.0 g / dL
A : Bleeding does not occur
P :
▪ TTV
▪ Monitor Monitor HGB, HCT, and PLT
I :
▪ Monitor TTV
▪ valuesMonitor HGB, HCT, and PLT values
E :
▪ Lip mucosa looks moist, elastic skin
▪ TD: 76x / min
▪ N: 120/70 m mHg
▪ S: 36.40C
▪ RR: 20x / minute
▪ Pain Scale: 0/10
▪ WBC: 8.60 x 103/ µL
▪ PLT: 104 x 103/ µL
▪ HCT: 36.4%
▪ HGB: 13.0 g / dL
R : Bleeding does not occur
 Laboratory examination results on September 21, 2019 at 00:23 Wita
No RM : 38066
Name : An. RA
Birth date : 3/16/2014
Check date : 21/09/2019
Reference
Parameter Result Unit Remarks
Value

WBC 3.9 10 ^ 9 / l 3.5 - 10.0

LYM 1.6 10 ^ 9 / l 0.5 - 5.0

LYM% 42.0 % 20.0 - 50.0

MID 0.3 10 ^ 9 / l 0.1 - 1.5

MID% 8.2 % 2.0 - 15.0

GRA 2.0 10 ^ 9 / l 1.2 - 8.0

GRA% 49.8 % 35.0 - 80.0

HGB 11.2 g / dl 11.5 - 16.5 L

MCH 27.4 pg 25.0 - 35.0

MCHC 32.6 g / dl 31.0 - 38.0

RBC 4.08 10 ^ 12 / l 3:50 to 5:50

MCV 84.0 75.0 - 100.0

HCT 34.3 fl% 35.0 - 55.0 L

RDWa 53.3 30.0 - 150.0

RDW% 12.1 fl% 11.0 - 16.0

PLT 147 10 9 / l 150-400 L

MPV 7.5 fl 8.0 - 11.0 L

PDWa 10.3 0.1 - 99.9

PCT 0.11 0:01 - 9.99

P-LCR 11.9 fl%% 0.1 - 99.9

 Results of laboratory examination dated 23 September 2019 at 6:22 pm
No. RM:38066
name: An. RA
Birth date : 03/16/2014
Check date : 23/09/2019

Reference
Parameter Result Unit Remarks
Value

WBC 2.8 10 ^ 9 / l 3.5 - 10.0 L

LYM 1.7 10 ^ 9 / l 0.5 - 5.0

LYM% 58.1 % 20.0 - 50.0 H

MID 0.2 10 ^ 9 / l 0.1 - 1.5

MID% 7.7 % 2.0 - 15.0

GRA 0.9 10 ^ 9 / l 1.2 - 8.0 L

GRA% 34.2 % 35.0 - 80.0 L

HGB 11.7 g / dl 11.5 - 16.5

MCH 26.9 pg 25.0 - 35.0

MCHC 32.9 g / dl 31.0 - 38.0

RBC 4.34 10 ^ 12 / l 3:50 to 5:50

MCV 81.9 75.0 - 100.0

HCT 35.5 fl% 35.0 - 55.0

RDWa RDWa 51.8 30.0 - 150.0

RDW% 12.1 fl% 11.0 - 16.0

PLT 167 10 9 / l 150 - 400

MPV 7.5 fl 8.0 - 11.0 L

PDWa 10.1 0.1 - 99.9

PCT 0.12 0.01 - 9.99

P-LCR 11.4 fl%% 0.1 - 99.9

 CHAPTER IV
DISCUSSION

In the chapter discussion of this case, the author will discuss the gap between
the case review with a review of theories about Nursing Care in Mrs. SC with DHF.
The diagnosis that appeared in Mrs. SC according to priority are:
A. Nursing Diagnosis that appears
1. Hypertherm associated with the disease process (inflammation of thevirus
dengue)
Hyperthermia is an increase in body temperature above normal> 37.5ºC. With
the limitation of characteristics namely redness of the skin, body temperature rises
above the normal range, the frequency of breathing increases, convulsions or
convulsions, warm palpable skin, tachycardia, and tachypnea (Wilkinson & Ahern,
2012).
This problem arises because of the inflammatory process (viremia) that
responds due to infection and increases the set points in the hypothalamus so that a
fever occurs. After reviewing the finding of data such as the patient's body feels hot,
restless, with a patient temperature of 38.2 ° C, the results of laboratory tests on October
14, 2019 with the results of platelets 30 103 /L, Hematocrit 39%. The clinical
symptoms above indicate an increase in body temperature in patients infected with
dengue virus. The dengue virus enters the body through the bite of the Aedes aegypti
mosquito.
Based on the signs and symptoms, the authors include the problem of
hyperthermia as the first problem priority. An increase in body temperature causes an
increase in capillary permeability of blood vessel walls so that intravascular fluid moves
to extravascular fluid. This can eventually lead to the risk of lack of fluid volume
(Widagdo, 2012).
The interventions carried out were to assess the general condition and vital
signs of the patient (pulse, temperature, breathing) to find out the general condition of
the patient, encourage the patient to wear thin clothing and absorb sweat to avoid
increasing body temperature, give and teach the family warm water compresses to
independent treatment when the patient returns to fever and take collaborative measures
to administer 1 gram of drip sanmol when the temperature is more than 38ºC, anti-
pyretic to help lower body temperature by lowering the hypothalamus set point at the
central body temperature control in the brain (Suriadi & Yuliani, 2006).
Implementation of nursing is carried out such as reviewing complaints and
vital signs of the patient. Encourage patients to wear clothing that absorbs sweat,
teaches correct compresses of warm water to the family and collaboration for
administering 1 gram of drip sanmol. Nursing evaluations obtained are hyperthermic
problems related to the disease process (inflammation of thevirus dengue) resolved on
the third day. Strengthened by the patient said he did not feel the heat in his body, the
temperature of 37.1ºC.
2. Nausea is related to digestive system disorders
Nausea is an uncomfortable feeling in the back of the throat or stomach which
can cause vomiting (Tim Pokja SDKI DPP PPNI, 2017).
This problem arises because when the assessment was carried out on October
14, 2019 the patient said no appetite, and nausea. The patient looked pale, with body
weight before and during illness remained 56 kg, the patient ate only used up ½ portion.
This problem arises as a disease process that affects the gastrointestinal system. The
virus can also be attached to the digestive tract which can cause stomach acid to
increase. The increase in stomach acid causes irritated stomach walls which can over
time make bleeding in the gastrointestinal which causes melena and epigastric pain. In
addition, an increase in stomach acid can cause nausea and vomiting so that patients
become anorexic and their nutritional needs are reduced (Ngastiyah, 2012).
The author prioritizes the problem of nausea as a second priority because the
patient has experienced an actual problem that is anorexia and nausea resulting in a
decrease in nutritional intake resulting in nutritional deficiencies. Nutrition is a basic
human need that must be met, if physiological needs are met will have a positive impact
on the achievement of patient recovery (Hidayat, 2006).
Nursing interventions carried out are the identification of factors causing
nausea, give small portions but often to prevent gastric distension, encourage adequate
rest and sleep, collaboration with antiemetics. Implementation of nursing is carried out
by identifying the factors causing nausea, providing small but frequent portions of food,
encouraging adequate rest and sleep, collaboration providing antiemetics (Gastrofer 40
mg, Narfoz 8 mg).
 Nursing evaluations found that nausea problems related to digestive system
disorders were partially achieved, with the patient's subjective data saying little
appetite, still nausea, no vomiting. and the patient's objective food data runs out of 1/2
portion.
3. Risk of bleeding associated with thrombocytopenia
Risk of bleeding is a condition that is at risk of decreasing blood volume that
can interfere with health (Wilkinson & Ahern, 2012). When the assessment was carried
out on October 14, 2019, there were red spots on the legs and temples examining
platelets 30 103 /L and hematocrit 39%.
This problem arises because of decreased platelet function and decreased
coagulation factors in the body making it easier for spontaneous bleeding in small blood
vessels such as capillaries to manifest red spots on the skin (ptekia). Thrombocytopenia
occurs due to shortening of platelet age due to excessive destruction byvirus dengue.
Viruses attached to the surface of platelets will cause immune complexes on the surface
of platelets until the platelets become damaged. This will result in thrombocytopenia or
a reduced platelet count which leads to bleeding, besides that platelet damage also
causes the liver to work and excess lymph to destroy the damaged platelets. This results
in hepatomegaly and splenomegaly which can cause pain (Ngastiyah, 2012).
The authors prioritize this as a third problem because the risk of bleeding
associated with thrombocytopenia can trigger a child to experience spontaneous
bleeding in small blood vessels such as capillaries manifesting red spots on the skin
(ptekia) (Widagdo, 2012).
Nursing interventions carried out are assessing the general condition and signs
of bleeding such as nosebleeds and black bowel movements to determine the patient's
condition and to recognize the signs of bleeding, monitor platelet results every day to
determine leakage of blood plasma and the possibility of bleeding in patients.
Implementation of nursing is carried out by assessing the general condition
and the presence of bleeding signs such as nosebleeds and black bowel movements,
monitoring the results of the patient's platelet examination every day. The evaluation
found that the problem of bleeding risk as evidenced by thrombocytopenia did not
occur, which was marked by platelet values increasing to 144 103 /L, Hemoglobin
14.3 g / dL and hematocrit 38.1%. The action plan taken is to continue the intervention.
4. The risk of shock is related to bleeding excessive, intravascular fluid
displacement to extravascular Shock
risk is a condition that is at risk of having insufficient blood flow to body
tissues which can result in life-threatening cellular dysfunction (Wilkinson & Ahern,
2012). This problem arises because when the assessment was carried out on October
14, 2019 there was an increase in body temperature, a decrease in platelets to 30 103
/L and red spots on the limbs and hands. The reduced coagulation factor in the body
facilitates spontaneous bleeding in capillary blood vessels and red spots appear on the
skin so that it can trigger the risk of shock due to internal bleeding.
The author prioritizes the fourth problem because the risk of shock is related
to bleeding excessive, the transfer of intravascular fluid into extravascular because the
patient is at risk of internal bleeding (platelets 30 103 /L), but no sign of serious
bleeding has yet been demonstrated as a result of hemoglobin 13.2 g / dL (Wilkinson
& Ahern, 2012).
The interventions carried out are monitoring vital signs and decreasing
platelets in patients to prevent clinical signs, suggesting patients to bedrest to rest the
patient to prevent complications, and collaborating with platelet monitors every day to
find out leakage of blood plasma and possible occurrence bleeding in the patient.
The implementation that is carried out is monitoring vital signs and platelet
decline in patients, encouraging patients to bedrest (bed rest) and collaborating with
platelet monitoring every day. Evaluation found that the risk of shock is associated with
excessive bleeding, the transfer of intravascular fluid to extravascular does not occur
which is characterized by a temperature of 36.8oC, pulse 84x / min, capillary refill less
than 3 seconds, respiratory rate 20x / min, increased platelets to 144 103 /L.
 CHAPTER V

CONCLUSIONS AND SUGGESTIONS

A. Conclusions

1. Dengue fever or dengue hemorrhagic fever is an acute febrile disease found in

the tropics, with a geographical spread similar to malaria. Dengue fever is
spread to humans by the Aedes aegypti mosquito. This disease is shown through
the sudden appearance of fever, accompanied by severe headaches, joint pain
and rashes. Because of frequent bleeding and shock, the death rate is quite high,
therefore any patient suspected of suffering from Dengue Fever at any level
must be immediately taken to the doctor or hospital, bearing in mind that at any
time they may experience shock / death.
2. The main prevention of dengue lies in eliminating or reducing the dengue
mosquito vector. By burying used goods that can hold water, draining water
reservoirs and hoarding used goods or garbage. Or we can also hunt larva.

B. SUGGESTION

1. It is hoped that the community will be more concerned about maintaining

the cleanliness of the surrounding environment and participating in
maximizing dengue fever activities.
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