NURSING CARE PATIENT "DM" WITH DENGUE FEVER DAY-4, WITHOUT

WARNING SIGN AT WARD 2A BIMC HOSPITAL NUSA DUA

MAY 17TH – MAY 19 TH 2016

A. Assessment
The initial assessment was conducted on May 17th, 2016 At 09:00 pm at BIMC
Hospital Nusa Dua. Data were obtained through interviews with patients, observation,
physical examination and medical records of patients. The results of data collection that
has been done is as follows:
1. Identity
Patient Patient’s Family
Name : “DM” : “MR”
MRN : 165734
Age : 31 years old : 57 years old
Gender : Female : Female
Nationality : Russian : Russian
Address : Jalan Pantai Brawa no. 34
Relation with Patient : Mother
Insurance : Allianz International
Medical Diagnose : Dengue fever day-4, without warning sign

2. Health History
a. Main Complain
Fever and nausea
b. History Of Recent Illness
Transferred from BIMC KUTA Hospital:
Patient presents with fever and weakness. The fever started on 12 May 2016. She was
then came to BIMC Kuta Hospital for consultation and having several blood tests.
Her NS1 Antigen was positive. She also has runny nose since several days earlier.
Currently, she feels weak and having losses of appetite; Fever already subsided. No
 signs of spontaneous bleeding. Last menstrual period was 1 May 2016. Allergy: No
Known Drugs Allergy (NKDA).
Medical Diagnose : Dengue fever day-4, without warning sign.
c. Past Medical History
None significant

3. Bio - Psycho - Social – Spiritual Data

 Breathing
Before hospitalize and when assessments patient haven’t complain in breathing
 Meal and Drink
Patient said that her last meal in breakfast time, drink 1 glasses of water (±250 ml)
since this morning
 Elimination
1) Defecate
When assessment patient said that he have defecate this morning. Normal
consistency. Normal habit is once daily.
2) Urination
When assessment patient said that he had urination once (300 cc) at 18.00. urine
colour is yellow
 Movement and Activity
Self Care Ability 0 1 2 3 4
Eating/Drinking √
Bathing √
Toileting √
Dressing √
Walking √
Mobilization on √
bed

0 : Independent 2 : Needs Help 3 : Needs help and tools

1 : Using Tools 4 : Does not do
  Body Temperature
When assessment her body temperature is 37,80C (36,50C – 37,50C)
 Comfort
Patient said that she nausea, didn’t want to eat and drink. Sometimes she feel heavy
head (headache).
 Social/Communication
Patient usually use Russian/English to communication and patient able to
communicate without interruption
 Recreation
Patient said that he usually going to beach for refreshing

Physical Examination
1. Vital Sign
BP : 100/70 mmHg
T : 37.8 0C
Pulse : 89 x/mnt
HR : 18 x/mnt
Sa O2 : 99% on RA
2. Conscious :
GCS : 15
Eye :4
Motorik :5
Verbal :6

3. General Condition
a. General appearance : Slight weak
b. Illness / Pain: Medium
P : Dengue Virus
Q : Throbbing
R : Constant and only in head
S : scale is 4 (0-10)
 T : since yesterday.
c. Nutritional Status: Normal
BW: 75 kg Height: 175 cm
Attitude: Calm
d. Personal hygene: clean enough
e. Orientation time / place / person: Good
4. Head To Toe Examination
a. Eyes: PERRL 3/3 mm, pink palpebral conjungtivae, anicteric sclerae, not sunken
b. Nose: slight congested, minimal serous discharge, runny nose
c. Throat: Pharynx and tonsils: no signs of inflammation
d. Neck: enlarged lymph on both submandibular area; non tender
e. Mouth: Lips and oral mucosa: dry
f. Chest: Heart: S1S2, normal rate regular rhythm
g. Lungs: symmetric chest expansion, clear breath sound, no rales, no wheezes
h. Abdomen: soft, hyper active bowel sound, no tenderness, liver and spleen are not
palpable, no costovertebral angle tenderness, no defans
i. Extremities: warm, brisk capillary refill, no edema, no rash
j. Thorax
 Heart
1. Pulse: 89 x / min
2. Strength: Strong
3. Rhythm: Regular
 Inspections: There pulsation
Palpation: Palpable pulses, strong heartbeat,
Percussion: dullness / dim (+) does not occur hepatomegaly
Auscultation: S1 S2 regular single
 Pulmonary
1. Breath Frequency: 18 x / min
2. Quality: Normal
3. Sound Breath: Vesicular
4. Cough: None
 5. The blockage of the airway: None
 Chest retraction: None
 Inspections: There is no chest muscle spasm, breath effort (-)
Palpation: Inspiration is longer than the expiratory
Percussion: Sonor / resonant
Auscultation: Vesicular + / +
k. Abdomen
 Peristaltic Guts: 8 x / min
 Bloating: None
 Pain Press: None
 Ascites: None
 Inspections: There is no lesions, skin colour lighter
 Auscultation: bowel sounds normal
Palpation: Tenderness (-)
Percussion: Sound tympani (+)
l. Genitalia
Unobservable
m. Skin
Skin rash on both of thigh since this morning but no itchy.

Supporting Data
1. Laboratory
TEST RESULT UNIT REFERENCE
RANGE
CBC
- Erythrocyte 4,44 10^6/uL 4,50 – 6,20
Count
- Haemoglobine 13,2 g/cL 13,0 – 18,0
- Hematocrit 39,3 % 40, 0 – 54,0
MCV, MCH, MCHC
- MCV 88,5 fL 81,0 – 96,0
- MCH 29,7 Pg 27,0 – 36,0
- MCHC 33,6 g/L 31,0 – 37,0
- RDW 37,9 fL 37 – 54
- RDW-CV 11,9 % 11,0 – 16,0
- Leucocyte Count L 1,35 10^3/ul 4,0 – 10,0
Differential Leucocyte
Count
- Eosinophil 0,7 % 0–4
- Basophil 0,0 % 0–1
- Segmented L 42,3 % 50 – 70
Neutrophil
- Lymphocyte H 48,1 % 20 – 40
- Monocyte H 8,9 % 2–6
- Eosinofil Count 0,01 10^3/ul 0,00 – 0,40
- Basofil Count 0,00 10^3/ul 0,00 – 0,10
- Neutrofil Count L 0,57 10^3/ul 1,50 – 7,00
- Limposit Count L 0,65 10^3/ul 1,00 – 3,70
- Monocyte Count 0,12 10^3/ul 0,00 – 0,70
- Platelet Count L 119 10^3/ul 150 – 400
- PDW 11,3 fL 9,0 – 17,0
- MPV 10,0 fL 9,0 – 13,0
- P-LCR 25,0 % 13,0 – 43,0
- PCT L 0,12 % 0,17 – 0,35
 PROBLEM ANALYSIS

No Data Etiology Nursing Diagnose

1 DS: Patient feel headache since Aedes aegypti take the Acute Pain
yesterday.. Pain scale is 4 (0-10). dengue Virus
The pain is like Throbbing,
constan and just only in head. Bit a human
DO: Patien’s looks grimaced.
Dengue virus in blood
circulation / VIREMIA

DF (Dengue Fever)

Head pain or muscle pain

Acute Pain
2 DS : Patient feel a bit nausea Aedes aegypti take the Nausea
when she tried to eat and drink dengue Virus
more.
DO: Patient looks Slight weak Bit a human

Dengue virus in blood

circulation / VIREMIA

DF (Dengue Fever)

Nausea
3 DS: patient feel headache and slight Aedes aegypti take the Hypertermia
weak. dengue Virus
DO: Lips and oral mucosa patient’s
looks dry. Temperature 37.8oC.
Bit a human

Dengue virus in blood

circulation / VIREMIA

DF (Dengue Fever)

Fever

Hypertermia
 NURSING DIAGNOSIS

1. Nausea retated to dengue virus with evidenced by Patient feel a bit nausea when she tried
to eat and drink more
2. Acute pain related to diseases phatology with evidenced by patient looks grimace, verbal
report of pain pain scale about 4 (0-10). The pain is like Throbbing, constan and just only
in head.
3. Hyperthermia related to the dengue virus infection (viremia) with evidenced by Lips and
oral mucosa patient’s looks dry. Temperature 37.8oC.
 NURSING CARE PLAN

Date /
No Diagnose Goals and Criteria Results Nursing care plan Rational
Time
1 2 3 4 5 6
1 Tuesday, Acute pain related to After given nursing care for 1. Asses patient’s pain 1. Know about pain scale
May 17Th diseases phatology 2 x 24 hours. The pain can be 2. Monitor patient’s pain scale 2. To know affectivity of the
2016 at with evidenced by controlled expected outcome before and after medication medicine for the pain of the
09.00 am patient looks are: patient
grimace, verbal 1. Vital sign within 3. Provide/promote non 3. To make the patient relax
report of pain pain normal rage pharmacological pain
scale about 4 (0-10). 2. Patient not grimace management e.g, deep breath
The pain is like 3. Patient verbalize a 4. Monitor patient’s vital sign 4. To measure the cardiac
Throbbing, constant decrease of pain from 4 during pain condition of patient
and just only in head to 2 (0-10) 5. Collaboration with doctor to 5. Decrease painful
give pain medication
2 Tuesday, Nausea related to After given nursing care for 1. Suggest to eat slowly 1. Eat slowly to suppress the
May 17Th dengue virus with 2 x 24 hours patient can nausea reflex.
2016 at evidenced by Patient controlling nausea, the 2. Explain to use a deep breath to 2. A deep breath to suppress
09.00 am feel a bit nausea expected outcome are: suppress the nausea reflex the nausea
when she tried to eat 1. starts to gain her 3. Limit drink 1 hour before, 1 hour 3. In order the stomach is full
and drink more appetite back after and during the meal of water
 2. Identify the things that 4. Instruct to avoid the pungent 4. Smell of food will reduce
reduce nausea smell of food nausea
5. Collaboration with doctor to give
IV therapy if needed 5. To reduce nausea

3 Tuesday, Hyperthermia After given nursing care for 1. Monitor patient’s vital sign 1. To measure the cardiac
May 17Th related to the dengue 2 x 24 hours, the patient's condition of patient
2016 at virus infection temperature in normal range. 2. Monitor skin colour and 2. To measure the
09.00 am (viremia) with The expected outcome are: temperature temperature
evidenced by Lips 1. Temperature is 36,5- 3. Encourange patient to drink a lot 3. Helping to reduce the
and oral mucosa 37,0oC of water temperature
patient’s looks dry. 2. mucous membrane 4. Monitor intake and output 4. Avoid the dehydration
Temperature 37.8oC become moist 5. Provide compress as needed 5. Helping to reduce the
temperature
6. Collaboration with doctor to give 6. To reduce temperature
medication
 IMPLEMENTATION

NO No
Date / Time NURSING ACTIVITY FORMATIVE EVALUATION SIGN
Dx
1 Tuesday, 1,2,3 Observe vital sign BP: 100/70 mmHg, Temperature 37,8oC, Pulse 89x/min,
May 17Th HR 18x/min, Sa O2 99% on RA
2016 at
09.30 am 1 Assesment patient’s pain Patient said the pain scale about 4 (0-10). She feel pain
in head. Quality of pain is trobbing. She looks grimace.

10.00 am 1,2,3 Delegate in giving medication Nexium been inject by IV. No allergy reaction.
- Paracetamol (Farmadol) 500-1000mg PO. Paracetamol and telfast been give by oral.
This medication for fever and pain
- Esomeprazole (Nexium) 40mg IV OD.
This medication for nausea
- Telfast Plus (Fexofenadine Hcl
60mg+Pseudoephedrine Hcl 120 mg) 1 tab
PO BID. This medication for runny nose.

12.00 am 2 Suggesting to eat slowly. Limit drink 1 hour Patient eat ½ portion of muesli, ½ portion slice of fruit,
before, 1 hour after and during the meal 1 cup of tea, 1 yogurt
 16.00 pm 3 Monitoring intake and output Patient drink 3 glass until this morning. She didn’t
vomiting. Urine around 300cc. She looks Slight weak,
her lips looks dry.

18.00 pm 1,2,3 Observe vital sign and PLT BP: 100/70 mmHg,Temperature 37,5oC, Pulse 79x/min,
HR 18x/min, Sa O2 99% on RA. PLT 118 10^3/ul

20.00 pm 1 Assesment patient’s pain Patient said the pain scale about 5 (0-10). She feel
headache, pain in behind eye ball. Quality of pain is
trobbing. She looks grimace

20.30 pm 1,3 Delegate in giving medication. Paracetamol Paracetamol been given by oral. No allergy reaction
(Farmadol) 500-1000mg PO. This medication for
fever and pain
2 Wednesday, 3 Assesment patient’s pain Patient said the pain scale about 2. She feel better than
May 18Th yesterday, but still feel headache. Runny nose
2016 at
08.00 am 1,2,3 Observe vital sign and PLT BP: 110/70 mmHg,Temperature 37,3oC, Pulse 74x/min,
HR 18x/min, Sa O2 98% on RA. PLT 124 10^3/ul

10.00 am 1,2,3 Delegate in giving medication Nexium been inject by IV. No allergy reaction.
- Paracetamol (Farmadol) 500-1000mg PO. Paracetamol and telfast been give by oral.
 This medication for fever and pain
- Esomeprazole (Nexium) 40mg IV OD.
This medication for nausea
- Telfast Plus (Fexofenadine Hcl
60mg+Pseudoephedrine Hcl 120 mg) 1 tab
PO BID. This medication for runny nose.

12.00 am 2 Instruction to avoid the sharp smell of food. Patient said that she starts to again her appetite back,
Explain to use a deep breath to suppress the minimal of nausea.
nausea reflex.

14.00 am 3 Monitoring intake and output ½ portion of soup, ½ slice toast, 1 cup of tea, ½ portion
of chicken ricotta

18.00 pm 1,2,3 Observe vital sign. BP: 110/70 mmHg,Temperature 37,0oC, Pulse 82x/min,
HR 18x/min, Sa O2 99% on RA

21.00 pm 1,3 Delegate in giving medication Paracetamol been given by oral. No allergy reaction
Paracetamol (Farmadol) 500-1000mg PO. This
medication for fever and pain
 22.00 pm 1 Assesment patient’s pain Patient said the pain scale about 2. Minimal headache,
minimal pain behind eyeball. She feel better after have
madication
3 Thursday, 1,2,3 Observe vital sign and PLT BP: 110/70 mmHg, Temperature 37,0oC, Pulse 84x/min,
May 19Th HR 18x/min, Sa O2 99% on RA. PLT 120 10^3/ul.
2016 at
09.00 am
10.00 am 1 Assesment patient’s pain and mucous membrane. Patient said the pain scale about 2. Minimal headache,
minimal pain behind eyeball but still runny nose.
mucous membrane become moist
 EVALUATION

No NO
Date / Time SUMMATIVE EVALUATION SIGN
DX
1 Thursday, May 1 S: Patient said the pain scale about 2. Minimal headache, minimal pain behind eyeball but
19Th 2016 at still runny nose
10.00 am O: The patient was calm and relaxed
A: Acute pain is resolved
Q: Maintain the patient condition
2 Thursday, May 2 S: Patient said that feel comportable. She starts to gain her appetite back
19Th 2016 at O: The Patient was calm and relaxed
10.00 am A: Nausea is resolved
Q: Maintain the patient condition
3 Thursday, May 3 S: Patient feel better than yesterday.
19Th 2016 at O: Patient’s temperature within normal range. Mucous membrane become moist
10.00 am A: Hyperthermia is resolved
Q: Maintain the patient condition