Selasa, 17 Mei 2011
NURSING CHILDREN WITH Dengue Hemorrhagic Fever
A. UNDERSTANDING
DHF is an acute arbovirus infection that enters the body through the bite of a mosquito species aides. This disease often affects children, adolescents, and adults that is characterized by fever, sore muscles and joints. Dengue Hemorrhagic Haemoragic often called Fever (DHF).
B. Pathophysiology
Once the dengue virus enters the body, patients will experience symptoms due to complaints and viremia, such as fever, headache, nausea, muscle aches, sore all over body, ditenggorokan hyperaemia, rash and abnormalities that may appear on the reticuloendothelial system such as enlargement of the glands lymph nodes, liver and spleen. A rash on the DHF is caused due to congestion of blood vessels under the skin.
The main pathophysiological phenomena that determine the weight of disease and distinguish between DF and DHF is heightened permeability of capillary wall due to the release of substances anafilaktosin, histamine and serotonin and the activation system that resulted kalikreain intravascular fluid extravasation. This has reduced the volume of plama, the occurrence of hypotension, hemokonsentrasi, hipoproteinemia, effusion and shock.
The presence of plasma leakage into the extravascular ibuktikan with the finding of fluid in serous cavities, ie in the peritoneal cavity, pleural and perikard. Hypovolemic shock occurring as a result of loss of plasma, if not resolved soon there will be tissue anoxia, metabolic acidosis and death. Another cause of death in DHF is bleeding.Bleeding is usually associated with thrombocytopenia, impaired platelet function and abnormalities of platelet function.
Platelet aggregation function decline may be due to an immunological process as evidenced by the presence of immune complexes in blood circulation. Abnormalities of coagulation system caused by damage such as liver function is tebukti disturbed by the activation of coagulation system. The problem occurs whether or DIC in DHF / DSS, especially in patients with severe bleeding.
C. CLASSIFICATION DHF
WHO, 1986 classifying DHF according to the degree of the disease into 4 groups, namely:
First Degree
Fever accompanied by other clinical symptoms, without spontaneous bleeding. Heat 2-7 days, positive tourniquet test, trombositipenia, and hemokonsentrasi.
Degree II
Same with degrees I, coupled with spontaneous bleeding symptoms such as petekie, ekimosis, hematemesis, melena, bleeding gums.
Degree III
Characterized 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 is not teaba, blood pressure did not teatur (heart rate? 140x/mnt) limb palpable cold, sweating and skin looks blue.
D. SIGNS AND SYMPTOMS
In addition to the signs and symptoms displayed by the degree of illness, other dangejala signs are:
- Liver enlarged, reinforced with spontaneous pain reactions palpability.
- Ascites
- The fluid in the pleural cavity (right)
- Ensephalopati: seizures, agitation, coma sopor.
E. EXAMINATION AND DIGNOSIS
- Thrombocytopenia (? 100.000/mm3)
- Hb and PCV increased (? 20%)
- Leukopeni (may be normal or lekositosis)
- Isolation of virus
- Serology (H test): secondary antibody response
- In severe shock, check out: Hb, PCV repeatedly (every hour or 4-6 hours when it showed signs of improvement), hemostasis physiology, FDP, EKG, chest photos, BUN, serum creatinine.
F. NURSING
1. Assessment
1.1 Identity
DHF is a tropical disease that often causes the death of children, adolescents and adults (Effendi, 1995)
1.2 Main Complaint
Patients complain of fever, headache, weakness, heartburn, nausea and decreased appetite.
1.3 History present illness
Medical history showed headache, muscle pain, aches throughout the body, pain when swallowing, weakness, fever, nausea, and decreased appetite.
1.4 History of previous disease
No illness is specific.
1.5 History of family illness
History of DHF disease in other family members is crucial, because the disease DHF is a disease that can be transmitted through the bite of aedes mosquito aegipty.
1.6 Environmental Health History
Normally less clean environment, lots of clean water puddles like tin cans, old tires, where drinking water is rarely replaced water bird, bath rarely cleaned.
1.7 Historical Growth
1.8 Assessment Per System
1.8.1 Respiratory System
Tightness, bleeding through the nose, shallow breathing, epistaxis, symmetrical chest movement, percussion resonant, audible on auscultation ronchi, krakles.
System 1.8.2 Persyarafan
In grade III patients with anxiety and a decline in awareness and in grade IV to trjadi DSS
1.8.3 cardiovascular system
In grde I can occur hemokonsentrasi, positive tourniquet test, trombositipeni, in grade III to circulatory failure, rapid pulse, weakness, hypotension, cyanosis around the mouth, nose and fingers, in grade IV no palpable pulse and blood pressure can not be measured .
1.8.4 Digestive System
Dry mucous membranes, difficulty swallowing, tenderness in the epigastric, pembesarn spleen, liver enlargement, abdominal stretch, decreased appetite, nausea, vomiting, pain on swallowing, can hematemesis, melena.
System 1.8.5 urinal
Urine production declines, sometimes less than 30 cc / hour, will reveal sat painful urination, urinary red.
Integumentary System 1.8.6.
An increasing body temperature, dry skin, the grade I have a positive tourniquet test, occurred pethike, in grade III bleeding can occur spontaneously in the skin.
2. Nursing Diagnosis
2.1 Hipertermi associated with the process of dengue virus infection
2.2 Risks associated with the displacement of fluid deficit ciran intravascular to extravascular
2.3 Risk hypovolemik shock associated with excessive bleeding, intravascular fluid into extravascular emigration
2.4 The risk of interference is less than the fulfillment of nutritional needs of the body associated with the intake of nutrients that are not adekwat due to nausea and decreased appetite.
2.5 Risks associated dnegan happen perdarahn factor-facto reduction in blood clotting (thrombocytopenia)
2.6 Anxiety associated with client condition has deteriorated and perdaahan
2.7 Lack of knowledge related to the lack of information.
3. Nursing care plan.
DP: Hipertermie associated with the process of dengue virus infection
Objectives: Normal body temperature
Criteria results: The body temperature between 36-37
Muscle pain disappear
Intervention:
a. Give komres tap water
Rational: cold compresses will occur by conduction heat transfer
b. Give him / instruct the patient to drink plenty of 1500-2000 cc / day (based on tolerance)
Rational: To replace fluids lost due to evaporation.
c. Instruct the patient to wear thin and easily absorbs sweat
Rational: To provide a sense of comfort and easy thin clothing absorbs sweat and does not stimulate an increase in body temperature.
d. Observation on the intake and output, vital signs (temperature, pulse, blood pressure) every 3 hours once or more often.
Rational: Detecting early lack of fluids and to know the fluid and electrolyte balance in the body. Vital Signs is a reference to determine the patient's general condition.
e. Collaboration: the supplying of intravenous fluids and administration of drugs according to the program.
Rational: The liquid is very important for patients with high body temperature. Drug khususnyauntuk lowering the patient's body temperature.
DP 2. The risk of fluid volume deficit related to intravascular fluid into extravascular emigration.
Objective: There was no fluid voume devisit
Criteria: Input and output balanced
Vital signs within normal limits
No sign presyok
Warm Akral
Capilarry refill <3 sec
Intervention:
a. Monitor vital signs every 3 hours or more often
Rational: Vital sign helps identify fluctuations in intravascular fluid
b. Observation of capillary refill
Rational: Indications keadekuatan peripheral circulation
c. Observation on the intake and output. Note the color of urine / concentration, BJ
Rational: The decline of concentrated urine output with increased BJ suspected dehydration.
d. Suggest to drink 1500-2000 ml / day (based on tolerance)
Rational: To consume fluids orally
e. Collaboration: Giving intravenous fluids
Rational: May increase the amount of body fluids, to prevent hipovolemic shock.
DP. 3 Risks associated with bleeding shock hypovolemik excessive intravascular fluid into extravascular emigration.
Objectives: Nothing happens hypovolemic shock
Criteria: Vital signs within normal limits
Intervention:
a. Monitor patient's general condition
Raional; To monitor the condition of the patient during treatment, especially when terdi bleeding. The nurse immediately know the signs presyok / shock
b. Observation of vital signs every 3 hours or more
Rationale: Nurses need to continue mengobaservasi vital sign to ensure it does not happen presyok / shock
c. Explain to patients and families a sign of bleeding, and immediately report if there is bleeding
Rational: By involving family psien and then the signs of bleeding can be immediately known and a fast and appropriate action can be immediately given.
d. Collaboration: Giving intravenous fluids
Rational: intravenous fluids needed to overcome a severe loss of body fluids.
e. Collaboration: checks: HB, PCV, trombo
Rational: To determine the level of leakage of blood vessels that experienced by the patient and for reference to further action.
DP. 4 The risk of disruption nutritional needs less than body requirements related to inadequate nutrient intake due to nausea and decreased appetite.
Objective: There was no need for nutritional disorders
Criteria: There are no signs of malnutrition
Showed a balanced weight.
Intervention:
a. Review the history of nutrition, including foods that are preferred
Rationale: Identify deficiencies, suspect the possibility of intervention
b. Observation and record patient's food input
Rational: Monitors caloric intake / food consumption shortage of quality
c. Weigh BB every day (if possible)
Rational: Overseeing the reduction BB / oversee the effectiveness of interventions.
d. Give your food a little but often and / or eating between meals
Rational: Food a bit to reduce vulnerabilities and increase input also prevents gastric distension.
e. Give and Bantu oral hygiene.
Rationale: Increased appetite and input peroral
f. Avoid foods that stimulate and contain gas.
Rational: Lowering distention and gastric irritation.
DP. 5. The risk of bleeding associated with decreased blood clotting factors (thrombocytopenia)
Objective: There was no bleeding
Criteria: BP 100/60 mmHg, N: 80-100x/menit regular, strong pulse
There was no sign of further bleeding, platelets increase
Intervention:
a. Monitor signs of decline accompanied by clinical signs of platelet.
Rational: The decline of platelets is a sign of leakage of blood vessels at a certain stage can cause clinical signs such as epistaxis, ptike.
b. Monitor platelet counts every day
Rational: With platelet counts monitored every day, can know the level of leakage of blood vessels and the possibility of bleeding experienced by patients.
c. Instruct the patient to a lot of rest (bedrest)
Rational: the patient activity can cause uncontrolled bleeding.
d. Give an explanation 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 early handling in case of bleeding.
e. Anticipation of bleeding: use a soft toothbrush, pet oral hygiene, give it 5-10 minutes after each pressure take blood.
Rationale: Preventing further bleeding.
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