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2 Dengue Hemorrhagic Fever Nursing Care

Plans
ByMattVera,RN Dec22,2011

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Definition
Dengueis transmitted by the bite of anAedesmosquito infected with any one of the four dengue
viruses. It occurs in tropical and subtropical areas of the world. Symptoms appear 314 days after
the infective bite. Dengue fever is a febrile illness that affects infants, young children and adults.
Symptoms range from a mild fever, to incapacitating high fever, with severe headache, pain behind
the eyes, muscle and joint pain, and rash. There are no specific antiviral medicines for dengue. It is
important to maintain hydration. Use of acetylsalicylic acid (e.g. aspirin) and nonsteroidal antiinflammatory drugs (e.g. Ibuprofen) is not recommended.
The symptoms of Dengue Hemorrhagic Fever (DHF), on the other hand, are similar to those of
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dengue but patient becomes irritable or restless, blood chemistry shows gradual decrease in platelet
count. The symptoms are usually followed by a shock-like state.

NursingCarePlans
Here are nursing care plans for patients with DHF.

IneffectiveTissuePerfusion
NDx:Ineffective tissue perfusion related to decreased HgB concentration in the blood secondary to
DHF 1
A mosquito which carries the dengue virus is called Aedes aegypti. The said mosquito comes in
contact with a person and bites the person. The dengue virus will flow through the bloodstream and
destroys blood components. Patients with dengue often has decreased WBC, platelet &
haemoglobin count. Hemoglobin count is used to measure oxygen carrying capacity of the blood.
Hemoglobin carries oxygen. Therefore, if there is decreased haemoglobin, there is also decreased
oxygen that reaches the different tissues of the body.

Assessment

Objectives

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Nursing
Interventions

Rationale

Expected
Outcome

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1. Establish

1. To gain

Rapport
2. Monitor

pts trust
2. To obtain

Vital Signs

baseline

3. Assess
patients

data
3. To assess

condition

contributing

4. Note
customary

factors
4. For

baseline data

comparison

5. Determine
presence of

with current
findings

dysrhythmias
6. Perform

5. To
identify

blanch test

alterations

Short Term:After 4

7. Check for
Homans sign

from normal
6. To

hours of NI, the pt

8. Note

identify /

will demonstrate

determine
adequate

The pt shall have

behaviours to

presence of
bleeding

improve

9. Elevate

perfusion

behaviours to

HOB
10.

7. To
determine

improve

Encourage

presence of

quiet &
restful

thrombus
formation

atmosphere

8. To

11. Instruct
to avoid

determine
risk of

tiring
activities

anemia
9. To

12.
Encourage
light

promote
circulation

Subjective:
(none)Objective:
Decreased
WBC
Decreased
platelet
Decreased
HgB
Decreased
capillary refill
time
Dysrhythmias
Altered
LOC
Fever

circulation.

Chills
Long Term:After 4
Diaphoresis

days of NI, the pt

will demonstrate
increased
perfusion as
appropriate

demonstrated

circulationThe pt
shall have
demonstrated
increased
perfusion as
appropriate

ambulation

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13.
Encourage

10. To
promote

use of
relaxation
techniques

comfort &
decrease
tissue O2

14.
Administer
medications

demand
11. To
decrease
cardiac
workload
12. To
enhance
venous
return
13. To
decrease
tension and
anxiety level
14. To treat
underlying
cause

Hyperthermia
NDx: Hyperthermia
When a person comes in contact with a mosquito, Aedes aegypti, the dengue virus flows through the
bloodstream. As the compensatory mechanism of the body, it will raise its temperature to allow the
immune system to work better and to deteriorate the condition of the invaders thus causing
hyperthermia.

Assessment

Objectives

Nursing
Interventions

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Rationale

Expected Outcome

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S> (none)O>
Short Term:After 4
Temp of
39.8 or
higher
Flushed
skin
Skin
warm to
touch
Chills
Increased
RR
Tachycardia

hours of NI, pts

temperature will
decrease from 39.8
to 37.
Long Term:
After 3 days of NI,
the pt will identify
underlying factors
& importance of
treatment as well
as s/sx requiring

Convulsions
Sweating

further evaluation
or intervention

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1. Establish

1. To gain

Rapport
2. Monitor
Vital Signs

pts trust
2. To obtain
baseline data

3. Assess
neurologic
response,

3. To
evaluate
effects &

note LOC &

orientation,
reaction to

extent of
hyperthermia
4. To monitor

stimuli,
papillary
reactions &

heat & fluid

loss
5. To

presence of
seizures
4. Note
presence /

minimize
shivering
6. To reduce
body

absence of
sweating
5. Wrap

temperature
7. To reduce
body

extremities
with bath
towels

temperature
in areas of
high blood

decreased body

6. Provide
TSB q 15
minutes

flow
8. To reduce
metabolic

shall have

7. Apply
local ice
packs in

demands /
oxygen
consumption

axilla
8. Instruct
client to

9. To prevent
dehydration
10. To

have bed
rest
9. Instruct

support
circulating
blood

client to
increase OFI

volume and
tissue
perfusion

The pt shall have a

temperature from
39.8 to 37The pt
identified
underlying factors
and importance of
treatment as well
as s/sx requiring
further evaluation
or intervention

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10.
Administer
replacement

11. To restore
normal body
temperature

fluids
11.
Administer

12. To
determine
effectiveness

antipyretics
12. Reassess
temperature

of
interventions
done

q 15 minutes

SeeAlso:
Nursing Care Plans

MattVera,RN
http://nurseslabs.com

MattVeraisaregisterednurseandoneofthemaineditorsforNurseslabs.com.Enjoyshealthtechnologyandinnovations
aboutnursingandmedicine,ingeneral.

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