Nursing Assessment

Assessment of a patient with DHF should include:

Evaluation of the patients heart rate, temperature, and blood pressure.

Evaluation of capillary refill, skin color and pulse pressure.

Assessment of evidence of bleeding in the skin and other sites.

Assessment of increased capillary permeability.

Measurement and assessment of the urine output.

Nursing Diagnosis
Based on the assessment data, the major nursing diagnoses for a patient with DHF are:

Risk for bleeding related to possible impaired liver function.

Deficient fluid volume related to vascular leakage.

Pain related to abdominal pain and severe headaches.

Risk for ineffective tissue perfusion related to failure of the circulatory system.

Risk for shock related to dysfunction in the circulatory system.

Nursing Care Planning and Goals

The goals in a patient with DHF are:

Be free of signs of bleeding.

Display laboratory results within normal range for individuals.

Maintain fluid volume at a functional level.

Report pain is relieved or controlled.

Follow prescribed pharmacologic regimen.

Demonstrate adequate tissue perfusion.

Display hemodynamic stability.

Be afebrile and free from other signs of infection.

Nursing Interventions

Nursing interventions appropriate for a patient with DHF include:

Blood pressure monitoring. Measure blood pressure as indicated.

Monitoring pain. Note client report of pain in specific areas, whether pain is
increasing, diffused, or localized.

Vascular access. Maintain patency of vascular access for fluid administration or

blood replacement as indicated.

Medication regimen. There must be a periodic review of the medication regimen

of the client to identify medications that might exacerbate bleeding problems.

Fluid replacement. Establish 24-hour fluid replacement needs.

Managing nose bleeds. Elevate position of the patient and apply ice bag to the
bridge of the nose and to the forehead.

Trendelenburg position. Place the patient in Trendelenburg position to restore

blood volume to the head.

Evaluation
A successful nursing care plan has achieved the following:

Absence of signs of bleeding.

Displayed laboratory results within normal range for individuals.

Maintained fluid volume at a functional level.

Reported pain is relieved or controlled.

Followed prescribed pharmacologic regimen.

Demonstrated adequate tissue perfusion.

Displayed hemodynamic stability.

Afebrile and free from other signs of infection.

Nursing Assessment Nursing Care Plan for Dengue Fever

1.

Review the basic data, the need for bio-psycho-social-spiritual patients from various sources
(patients, families, medical records and other health team members).

2.

Identify potential sources and available to meet patient needs.

3.

Review the history of nursing.

4.

Assess the increase in body temperature, signs of bleeding, nausea, vomiting, no appetite,
heartburn, sore muscles and joints, signs of shock (rapid and weak pulse, hypotension, cold
and moist skin, especially on the extremities, cyanosis , restlessness, decreased
consciousness).

Nursing Diagnosis Nursing Care Plan for Dengue Fever

1.

Hypovolemic shock related to hemorrhage

2.

Imbalanced Nutrition: Less than body requirements related to nausea, vomiting, no

appetite.

3.

Increased body temperature related to the process of dengue virus infection.

4.

Risk for bleeding related to thrombocytopenia.

5.

Deficient Fluid Volume related to increased capillary permeability, bleeding, vomiting and
fever.

6.

Deficient Knowledge: about the disease process related to a lack of information.