NURSING CARE FOR Mr.

K
WITH DENGUE HEMORRHAGIC FEVER
ANGGREK ROOM SOETIJONO BLORA HOSPITAL

CREATED BY:

1. DITA YULIARTHA (2B)

2. MARCHILIA PUJA P. (2B)

POLTEKKES KEMENKES SEMARANG

PRODI DIII KEPERAWATAN BLORA
2020
A. ASSESSMENT
 Identity
Name : Mr. K
Age / date of birth : 48 years old / January 1, 1972
Profession : Employee
Education : Senior high school
Gender : Male
Religion : Islam
Mental status : Cooperative
Address : Blora
Date of hospital admission: October 29, 2019
Register number : 215752
Medical diagnosis : Dengue Hemorrhagic Fever
Date of review : October 29, 2019, 08.00 a.m

Person in charge
Name : Mrs. B
Age : 45 years old
Work :-
Address : Blora
Relationship with clients: Wife

 Main Complaint
1. The patient said fever, dizziness and weakness.
2. The patient also Said that He was nauseous and vomited

 Current History
 The patient said he had a fever since one week ago. He felt weak and dizzy. the
patient said it was compressed but still had a fever. and he said that he was
nauseous and vomited because he didn't want to eat. He was taken by the family
to Soetijono Hospital blora
 Past Medical History
The patient said he had never before been sick like this.

 Family Health Condition

The patient said no family suffered from this illness.

 Physical Assesment
General condition: Weak
Level of consius : Compostment

Current complaint : 1. The patient said fever, dizziness and

weakness.

2. The patient also Said that He was nauseous

and vomited

Performanca : Thin
Body Weight : 50kg
Body Height : 158 cm
Vital sign
Blood pressure : 120/70 mmHg
Respiration : 22x/minutes
Pulse : 82x/minutes
Temperature : 39C

Head to Toe Examination

 Head and neck :
1) Face. : Redness of the face, swelling around the eyes, lacrimation and
photobia, painful eyeball movements.
2) Mouth. : Dry mouth mucosa, bleeding gums, dirty tongue, (sometimes)
cyanosis.
3) Nose. : Epitaxis
4) Throat. : Hyperemia
5) Neck. : Enlarged lymph glands in the upper corner of the jaw in the
posterior cervical area.
 Thorax :

Epigastric tenderness, shallow breathing.

 In Stage IV:

Palpation. : Vocal - fremitus shakes less.

Percussion. : Sound of a deaf lung.

Auscultation. : Obtained weak vesicular breath sounds.

 Heart :
 Inspection : No heart enlargement
 Palpation : Location of Ics 5 left midclavicle
normal strength
 Percussion : The location of the heart sounds dim
 Auscultation : Sounds of heart I and sound of heart II, inaudible sound of
heart III and sound of heart VI
 Abdomen :
 Palpation. : There is enlargement of the liver and lymph, in a state of
dehydration skin turgor can decrease, suffi dulness, balote ment point (Stage
IV).
 Musculoskeletal :
The client can still move his limbs, there are no disorders or abnormalities.

 The Pattern of a Day Life

a. Eat/ drinking
Before Illness: The patient to eat three times a day with a portion of
many, rarely eat fruits, patient drinking water 6-8 cups a day.

During Illness: The patient to eat three times a day but after eating,

patient felt queasy, so eating just a little. Drink 4-5 cups a day.

b. Sleep / Rest

Before Illness: Patient say take a nap 1-2 hours / day, 6-7 hours / day

sleep

During Illness: Patient cannot take a nap, sleep for 1-2 hours / day,

because fever and dizzy.

c. Elimination Defecation / urination

Before Illness: Patient say defecation 2-3 x / day, urinate 3-4 x / day

During Illness: Unable to defecate, urinating just comes out a little.

 d. Personal Hiyegine
Before Illness: The patient said he was diligent in self-care, for
example: taking a bath twice a day, brushing his teeth every time he
bathed and going to bed.
During Illness: Patient say only wipe with wet washcloth twice a day.

 Therapy

IVFD Ringer Laktat 20gtt/m

Omeprazole 2X1 Caps AC
PCT tab 3X500 mg

 Supporting Investigation

Examination Results Normal Unit

Kimia Klinik

GDS 67 70-140 Mg/dl

Ureum 20 10-50 Mg/dl

Creatinin 0.78 0.7-1.3 Mg/dl

SGOT 15 0-37 U/L

SGPT 12 0-42 U/L

Natrium 144 135-155 Mmol/L

Kalium 3.7 5.5-3.6 Mmol/L

Chlorida 105 108-95 Mmol/L

Serologi
1
Salmonela Typhi H /80 Negative
Salmonela Typhi H 1
/80 Negative
Salmonela parayphi AH
1
/80 Negative
Salmonela paratyphi BH
1
/80 Negative
Salmonela paratyphi CH
1
/80 Negative
 1
Salmonela Typhi O /80 Negative
1
Salmonela paratyphi AO /80 Negative
1
Salmonela paratyphi BD /80 Negative
1
Salmonela paratyphi CD /80 Negative

Examination Results Normal Unit

Hematologi

WBC 52 4-10 Sel/mm3

RBC 4.54 4.5-5.5 Sel/mm3

HGB 12.2 14-18 Gr/dl

HGT 38.2 40-48 Vol %

MCV 84.1 76-96 %

MCH 26.7 27-32 %

MCHC 37.2 32-37

PLT 222 100-450 Sel/mm3

LYM % 30.4 %

MXD % 10.9 %

NEUT % 58.7 %

B. DATA ANALYSIS

NO Focus Data Etiology Problem

.
1. Subjective Data : increase in body process of dengue
Patients complain of fever and temperature virus infection
weakness
Objective Data :
Blood pressure. : 120/70 mmHg
Respiration : 22x/minutes
 Pulse : 82x/minutes
Temperature. : 39C

2. Subjective Data : Patients said decreased desire to nutritional

nausea and vomited eat imbalance is less
Objective Data : The patient looks than the body's
weak needs

C. NURSING DIAGNOSE
1. an increase in body temperature is related to the reaction of
the dengue virus infection process.

2. Impairment of fulfillment of nutrients less than the body's

needs is related to inadequate intake

D.. NURSING ACTION PLAN

Nursing Action Plan

Diagnose Objectives and Intervention Rational

outcome criteria.

an increase in body Risk does not occur 1.Monitor 1. To find out the
temperature is related temperature- TTV client is also
to the reaction of the Criteria results: the specific vital the right course of
dengue virus infection client's body signs action
process temperature
returned to normal. 2.encourage 2. To reduce body
Ds: The client said that clients to drink temperature and
it's been hot since one Ds: The client's plenty of water prevent dehydration
a week ago body temperature is 3. encourage
normal clients to use 3. To reduce body
Do: The client's body temperature and
feels hot Do: The client's clothes that can avoid other diseases
body is not hot absorb sweat
4. To replace the
TTV.TD:120/80m 4.Collaboration liquid that comes out
mhg in the
administration of of sweat and reduce
R: 16-20x / minute drug and fluid heat
N: 80-100x / minute therapy

S: 36°C
Impairment of The body's 1. Assess vital 1. To find out the
fulfillment of nutrients nutritional needs are signs client's vital signs 2.
less than the body's met. Help increase food
needs is related to 2. Give food that intake
inadequate intake Results criteria: the is easily
client can meet his swallowed like 3. To prevent or
Ds: -Clients say nutritional needs porridge avoid nausea
feeling sick, -Client
says lack of appetite Ds: the client is able3. Encourage 4. to find out the
to spend his food, clients to eat amount of nutrients
Do: The client looks the client's nausea is small portions that enter the body
weak gone and frequent
frequencies such 5. To find out the
Do:No complaints as giving 5 right therapy to use
of nausea. The tablespoons
client looks healthy porridge every
15 minutes

4. Record the
number of
servings of food
the client spends

5. collaboration
in the provision
of therapy

E. IMPLEMENTATION AND EVALUATION

Day/ Date Nursing

Diagnose Implementation Evaluation Nurse's name
Time

29-10-2019 1. Impaired 1. examine TTV: TD: S: The client says he Natalia

fulfillment of 120/70 mmhg R: still feels nauseous Sumihe
08.00 nutrients less 22x / minute
O: the client spends
 than the N: 82x / minute part of the meal
body's needs given
S: 39°C
related to
A: The problem has
inadequate 2. Provide food not been resolved P:
intake (porridge) to the Review interventions
client
11.00 3. Encourage clients
to eat a little but
often

4. record the number

of servings of food
spent. (client
11.05 consumes ½ portion
of food from the
hospital) 5. After
collaborating the
fluid used IVFD
Ringer Lactate
11.20 20gtt / m

12.10

08.00 2. The risk of 1. Monitor TTV: S: The client says Natalia

increasing body temperature Sumihe
TD: 120/80 mmhg R: starts to drop
body
20x / minute
temperature
O: The body
associated N: 72x / minute temperature of the
with the
S: 39°C touched head is not
reaction
too hot
process of 2. Encourage clients
dengue virus to drink lots of A: The problem has
infection water. (client does
08.30 not follow not been resolved
suggestions)
P: Review
3. encourage clients interventions
to use thin clothes
and absorb sweat.
(the client follows
the
recommendations)
09.00
4.after collaborating,
given drug therapy
PCT 3x500 mg

12.10