Nama : Silfia Istikomah

Kelas : PSIK 3B
NIM : 2019012210

ASKEP Dengue Hemorrhagic Fever (DHF)

MEDICAL CONCEPTS

A. Definition of dengue haemorragic fever

            DHF is an acute arbovirus infection that enters the body through the bite of aides
mosquito species. This disease often affects children, adolescents, and adults, characterized
by fever, muscle and joint pain. Dengue Hemorrhagic Fever is often called Dengue
Haemoragic Fever.
Dengue fever is a severe clinical manifestation of arbovirus disease. (Soedarmo
Sumarno, 2005).
Dengue is an acute arbovirus ( arthropod-borne virus)  infection transmitted by the
Aedes species mosquito. (Hasan Rusepno, 2007).
Dengue Hemorrhagic Fever is a disease caused by the dengue virus which belongs to
the arbovirus class through the bite of female Aedes aegypti mosquitoes. (Hidayat A. Aziz
Alimul, 2008).
Breakfast . Etiology 
  The cause of dengue hemorrhagic fever is the dengue virus. In Indonesia, the virus has
so far been isolated into 4 serotypes of Dengue virus which are included in Group B
arthropediborne viruses (arboviruses), namely DEN-1, DEN-2, DEN-3, and DEN-4.
(Nursalam Susilaningrum, 2005) .
  This disease is caused by the Dengue virus and transmitted by the Aedes mosquito. In
Indonesia, there are two types of Aedes mosquitoes, namely:
a. Aedes Aegypti    
1) Most often found   
2) Are mosquitoes that live in tropical areas, especially those that live and breed indoors, namely
in clear water reservoirs or water reservoirs around the house.   
3) At first glance, this mosquito looks streaked with white spots.   
4) Usually bite during the day, especially in the morning and evening.   
5) The flight distance is 100 meters   
b. Aedes Albopictus    
1) Place their habitat in clean water. Usually around the house or trees, such as banana trees,
used pandanus cans.   
2) Biting during the day   
3) The flight distance is 50 meters.   
    (Rampengan TH, 2007)
C . PATHOPHYSIOLOGY
After the dengue virus enters the body, the patient will experience complaints and
symptoms due to viremia, such as fever, headache, nausea, muscle pain, body aches,
hyperemia in the throat, rashes and abnormalities that may appear in the reticuloendothelial
system such as enlarged glands. lymph, liver and spleen. The rash in DHF is caused by
congestion of blood vessels under the skin.
The main pathophysiological phenomenon that determines the severity of disease and
differentiates DF and DHF is the increased permeability of capillary walls due to the release
of anaphylactosin, histamine and serotonin as well as activation of the calicreain system
which results in extravasation of intravascular fluid. This results in reduced plasma volume,
hypotension, hemoconcentration, hypoproteinemia, effusion and shock.
The presence of plasma leakage into the extravascular area is evidenced by the
discovery of fluid in the serous cavity, namely in the peritoneal, pleura and pericardial
cavities. Hypovolemic shock that occurs as a result of plasma loss, if not resolved promptly,
tissue anoxia, metabolic acidosis and death will occur. Another cause of death in DHF is
heavy bleeding. Bleeding is generally associated with thrombocytopenia, impaired platelet
function and abnormal platelet function.
Decreased platelet aggregation function may be due to immunological processes
proven by the presence of immune complexes in the bloodstream. Coagulation system
abnormalities are caused, among others, by liver damage, whose function has been shown to
be impaired by activation of the coagulation system. The problem of the occurrence of DIC in
DHF / DSS, especially in patients with heavy bleeding. 

KDM Deviation Model

D . DHF CLASSIFICATION 
            WHO, 1986 classifies DHF according to the degree of disease into 4 groups, namely:
Degree I
     Fever accompanied by other clinical symptoms, without spontaneous bleeding. Heat 2-7
days, positive tourniquet test, thrombocytopenia, and hemoconcentration.
Degree II
     Same with grade I, coupled with symptoms of spontaneous bleeding such as petechiae,
ecchymosis, hematemesis, melena, bleeding gums.
Degree III
     Characterized by symptoms of circulatory failure such as weak and rapid pulse (> 120x /
min) narrow pulse pressure (120 mmHg), decreased blood pressure, (120/80 ® 120/100 ®
120/110 ® 90/70 ® 80/70 ® 80/0 ® 0/0)
Grade IV
     The pulse is not palpable, the blood pressure is irregular (heart rate ³ 140x / min), the limb
feels cold, sweats and the skin looks blue.
E . SIGNS AND SYMPTOMS
            In addition to the signs and symptoms that are displayed based on the degree of the
disease, other signs and symptoms are:
-     Enlarged liver, spontaneous pain reinforced by touch reactions.
-     Ascites
-     Fluid in the pleural cavity (right)
-     Ensephalopati: convulsions, restlessness, sopor coma.
F . EXAMINATION AND DIGNOSIS            
-     Thrombocytopenia (£ 100,000 / mm 3 )
-     Hb and PCV increased (³ 20%)
-     Leukopenia (may be normal or leukocytosis)
-     Virus isolation
-     Serology (H test): secondary antibody response
-    At severe shock, check: Hb, PCV repeatedly (every hour or 4-6 hours when already showing
signs of improvement), Faal hemostasis, FDP, EKG, Chest photo, BUN, creatinin serum.
G . MANAGEMENT
            Indications for stay in suspected dengue virus infection:
-     Heat for 1-2 days accompanied by dehydration (due to heat, vomiting, insufficient intake) or
convulsions.
-     Heat for 3-5 days accompanied by abdominal pain, enlarged liver, positive / negative
tourniquet test, impression of severe pain (not wanting to play), increased hemoglobin and
PCV.
-     Heat accompanied by bleeding
-     Heat accompanied by shock.
            No or no shock:
1. Grade I and II:
a. Oral ad libitum or
b. Ringer's Lactate fluid infusion with a dose of 75 ml / Kg BW / day for children <10 kg or 50
ml / Kg BW / day for children <10 kg body weight, together given ORS drinks, fruit water or
sufficient milk.
       For cases showing symptoms of dehydration, it is advisable to drink as much and as
often as possible.
       If the child does not like drinking at all, the amount of intravenous fluids that must be
given should be in accordance with the patient's fluid needs within 24 hours which are
estimated as follows:
· 100 ml / Kg BW / 24 hours, for children <25 Kg
· 75 ml / KgBB / 24 hours, for children with weight 26-30 kg
· 60 ml / KgBB / 24 hours, for children with weight 31-40 kg
· 50 ml / KgBB / 24 hours, for children with weight 41-50 kg
· Other drugs: antibiotics if there is another infection, antipyretics for anti-fever, blood 15 cc / kg
/ day heavy bleeding.
With Shock:
2.  Grade III
a. Give Ringer's Lactate infusion 20 mL / KgBW / 1 hour
     If it shows improvement (the blood pressure is more than 80 mmHg and the pulse is palpable
with a frequency of less than 120 / min and warm akral), continue with Ringer's Lactate 10
mL / KgBB / 1 hour. If the pulse and blood pressure are stable, continue the infusion with the
amount of fluid calculated based on the fluid requirement within 24 hours minus the fluid that
has been entered divided by the remaining time (24 hours minus the time spent dealing with
shock). The calculation of the fluid requirement in 24 h is calculated as follows:
· 100 mL / Kg BW / 24 hours for children <25 Kg
· 75 mL / Kg BW / 24 hours for children with weight 26-30 Kg.
· 60 mL / Kg BW / 24 hours for children with a weight of 31-40 Kg.
· 50 mL / Kg BW / 24 hours for children with weight 41-50 Kg.
b. If one hour after using RL fluid 20 mL / Kg BW / 1 hour the tension is still measured to be
less than 80 mmHg and andi quickly weak, cold akral, then the patient gets plasma or plasma
expanders (dextran L or others) as much as 10 mL / Kg BW / 1 hour and can be repeated a
maximum of 30 mL / Kg BW within 24 hours. If the general condition persists, RL fluid is
continued as much as the fluid needs for 24 hours minus the fluid that has been entered
divided by the remaining time after being able to overcome the shock.
c. If one hour after giving Ringer's Lactate fluid 10 mL / Kg BW / 1 hour the blood pressure
decreases again, but is still measured to be less than 80 mmHg and the pulse is rapidly weak,
cold acral, then the patient must get as much plasma or plasma expanders (dextran L or
other). 10 Ml / Kg BW / 1 hour. And can be repeated a maximum of 30 mg / Kg BW within
24 hours.
 ASUKAN NURSING PATIENTS WITH DHF

A. Assessment 
1. Client Identity   
Name: TS
12 years old
TTL:    Buton 3 October 1999
Female gender
Religion:    Islam
Address:    Pasarwajo
Tribe / Nation:    Buton / Indonesia
First born
Medical Diagnosis: Dengue Hemorrhagic Fever
2. Parent Identity   
Father's Name: Mr. MS
Age: 37 Years
Education: Bachelor Degree I
Occupation: Private
Address: Pasarwajo
Islam
Tribe / Nation: Buton / Indonesia
Mother's Name: Mrs. MP
Age: 32 Years
Education: high school
Occupation: Self-employed
3. Identity of siblings   
No Name Age Relationship Health Status

1 F.S 5 years Little brother Healthy

4. Medical History   
a. Main Complaint: Heat   
b. Medical History Now   
Since 4 days ago, 02-05-2010, before entering the hospital, the client complained of fever,
coughing, and headache. The client was given paracetamol medication, the fever fell but soon
it rose again until it reached 40 0 C. On 06-05-2010 the family brought the client to the ER at
Bethesda General Hospital GMIM Tomohon for treatment. And the doctor recommended to
be hospitalized in Deborah's room. During the assessment on 07-05-2010 at 14.00, the client
said that the body still felt hot with a body temperature of 38 0 C and had received treatment
 for 1 day. The client said there were red spots on the hands and feet, decreased appetite for
nausea and vomiting twice, the client looked weak,
c. Past Medical History   
Previously, the client had never experienced a disease like what he currently has and was
never hospitalized.                                    
d. Family Health History  
The family said that in the family only the client experienced this kind of illness.
e. Environmental conditions   
The client lives with the client's parents and younger siblings, the place has tile roofs,
concrete walls, flur floors, consisting of 4 rooms for the client and the client's sister sleeps in
one room, the toilet and bathroom are in the house, the source of drinking mineral water
refills, electric lighting and garbage handling in the collection and then disposed of in the
trash. Type of tenement and adjacent to neighboring houses.
f. Psychosocial History    
The relationship between children and parents and younger siblings is harmonious, clients
include children who are quick to get along, close with peers, especially at home, the
relationship between children and their family and the surrounding environment is good, if
the client is angry, the client expresses feelings by crying or expressing feelings to parents ,
and if the client is happy the client expresses his feelings with a laugh.
g. Spritual History   
The client is Muslim. Clients always go to Sunday school services every Sunday, and other
children's worship activities. Clients are also taught by parents to always pray before eating,
before going to bed and getting up.
h. Hospitalization Reaction   
1) Children's understanding of illness and hospitalization  
At the time of the assessment, the client said that being sick was a frightening condition
because when he was sick he could not do his usual activities, could not go to school as usual,
and had to stay in the hospital to get treatment in the healing process.
2) Parents' understanding of illness and hospitalization  
At the time of the assessment, the client's parents say that being sick is a condition that is
worrying for every parent for his child, because it can make parents feel burdened and parents
ask about their child's illness, seem restless and pacing in the room because it is the first time
their child is hospitalized .
5. Activities of everyday life   
a. Nutrition   
     Before getting sick: The patient's appetite is good, the frequency of eating 3 times a day,
type of food: rice, fish, vegetables. Meal portions were spent. There are no restrictions or
food allergies.
     When examined: The meal portion is not finished (only 5-6 tablespoons). The client eats 3
times a day, the type of food; porridge, fish, soup, fruit. Lack of appetite, nausea and
vomiting 2x
b. Fluid   
     Before getting sick: Clients drink 6-7 glasses / day, the type of water, milk sometimes.
     When studied: Drink 10 glasses / day
     Type of water, and it is recommended to drink fruit juice
c. Elimination   
     Before getting sick: CHAPTER 1-2 times / day
     Flabby consistency
     Brown
     BAK 4-5 / day
     Clear yellow color
     When reviewed: The client has not CHAPTER
     BAK 6-7x / day
     Clear yellow color                      
d. Rest / sleep  
     Before getting sick: Naps for 1 hour, but sometimes not taking a nap because of playing
     Sleep 8-9 hours / day
     When studied: 1 hour nap / day
     10 hours of sleep per day
e.    Personal hygiene
    Before getting sick: Bathing twice a day, using soap, washing your hair using shampoo,
brushing your teeth twice a day with a toothbrush and toothpaste
     When studied: The client is only washed using a washcloth every morning.
f. Activity                                                        
     Before getting sick: Client activities to school and playing with clients' peers at home after
school
     When reviewed: The client is not active, the client only rest because of illness.
6. Physical Examination   
a. General circumstances   
     Clients appear weak, clients dress according to age, clean
b. Awareness   
     Composmentis
c. Vital sign   
     TD                  :    110/70 mmHg
     N                     :    92 x/m
     R                     :    22x/m
     Sb: 38 0 C
d. Anthropometry  
     TB: 135 cm
     Weight before illness: 28 kg
     BW when sick: 25 kg
7. Head to toe examination   
a. Head   
     Inspection : Round shape, black hair, even hair distribution, no scalp lesions,         
     Palpation   : no lumps and no tenderness        
b. Eye   
     Inspection: Left and right symmetrical movements of the eyeball, pink conjunctiva, sclera
not jaundiced.
     Palpation   : No tenderness and no lumps        
c. Nose   
     Inspection: There are nose hairs, good smell, no secretions, no bleeding.
     Palpation   : No tenderness, and no polyps felt        
d. Ear  
     Inspection: Left and right symmetrical, good hearing function, no cerumen, no bleeding.
     Palpation   : No lumps and no tenderness        
e. Mouth   
     Inspection : dry lips, dry oral mucosa, no stomatitis, no caries, no bleeding.        
f. Neck    
     Inspection: There was no enlargement of the jugular vein and thyroid gland
     Palpation   : No enlarged lymph nodes.        
g. Chest   
     Inspection: Symmetrical chest movements.
     Palpation   : No tenderness        
     Auskulatate : bronchovesicular breath sounds, no additional sounds such as Wheezing or
ronchi are heard   
     Percussion   : Resonant sound in the lungs, and deafening sound in the heart.        
h.    Abdomen
     Inspection: Flat stomach, no ascites,
     Palpation   : No tenderness, no enlargement of the liver        
     Auscultation: Peristaltic bowel sounds
     Percussion   : A tympanic sound.        
i. Upper limb     
     Inspection: Left and right symmetrical, attached IVFD RL 30tts / m in left hand. Good
ROM, muscle strength 5
     Palpation   : No adema, hot palpable acral.        
j. Lower limb     
     Inspection: Symmetric left and right, both legs can be moved, ROM is good, muscle
strength 5
     Palpation: No adema, hot palpable acral
k. Genetalia   
     Inspection: clean
l. Anus                                            
     Inspection: No haemorrhoids
     Inspection: Olive color, there are red spots,
     Palpation   : Good skin turgor, feels hot.        
B. Nursing Diagnosis
1. Hyperthermia is associated with a viral infection process characterized by   
DS:
- The client says the body feels hot      
DO :
- The client looks weak      
-       Sb 380C, N 92x/m
- Akral feels hot      
2. Impaired fulfillment of nutritional needs less than body needs associated with nausea and
vomiting, no appetite, which is indicated by   
DS:
- The client said decreased appetite, nausea and vomiting 2x      
DO :
- The food served is not finished (only 5-6 spoons)      
- Now he is 25 kg      
 - Lips look dry      
3. The potential for bleeding associated with thrombocytopenia, risk factors for further
bleeding:   
- Parents say they have red spots on both feet and hands      
- Looks red spots on the skin      
- Platelets 73,000 / dl      
- Leukocytes 1000 / dl      
- Attached IVFD RL 30 tts on the left hand.      
4. Changes in family processes associated with the condition of the child which is
characterized by   
DS:
- Parents wonder about their child's illness.      
DO :
- Parents are restless, and pacing the room.      

C. Nursing Care Planning 

No Date and Nursing diagnoses Nursing Planning Implementation Nursing
time Evaluation
 Nursing
Objectives / Intervention Rational
Criteria for
results
1 Friday Hyperthermia is The child showed 1.    Observation of 1.     Temperature 38.9- 14.00 hours 22.00 hours
vital signs within vital signs every 4 41.1 0 c indicates an 1.     Observing vital signs
07/05/2020 associated with a S:
viral infection normal limits hours acute infectious
process after 3 days of disease process.     Sb : 380c - The client said the
characterized by nursing action body still feels hot
2.     Giving     N : 92x/mnt
with the 2.    Give a warm
DS: compresses make     R : 22x/m O:
following compress
vasodilation - Akral feels hot
- The client says the criteria:     TD: 110/70 mmHg
3.    Instruct parents
body feels hot
- The    body to give at least ± 8-3.     Speed up the 2:15 p.m. - Sb: 37.8 0 c
evaporation process
DO : doesn't feel hot 9 glasses of water / -        N : 92x/m
through urine and 2. Apply a warm compress to the
day
- The client looks -    Temperature sweat in addition to forehead A:
weak and pulse within replacing lost body
normal limits of 4.    Instruct the child fluids 3. Encourage children to drink lots of The problem of
- Sb 380C, N 92x/m 0 0 water / guava juice ± 8-9 glasses / day increasing body
36.5   c-37.2   c not to wear a
- Akral feels hot 4.     To facilitate the temperature has
and 50-90 x / m blanket of thick evaporation process 14.30 not been resolved
clothing 4. Encourage clients to wear thin clothes
P:
5.    Instruct parents that absorb sweat easily
5.     Provide a sense of Continue nursing
to immediately 18.00 hours
comfort for the actions
change the client's
client's body. 5. Helping to change children's clothes
clothes if it is wet
with sweat because they are wet with sweat

6.    Give intravenous6.     Giving 14.00 hours

therapy and drugs intravenous therapy 6. Provide sanmol medicine ¾ tab
according to the to replace lost fluids
 doctor's program and drugs as Ocuson ¾ tab
preparations  Change IVFD fluids RL 30 tts / min
formulated for heat
reduction
2 Friday Impaired nutrition Children show 1. Serve easy to 1. Facilitate the 17.00 hours 22.00 hours
07/05/2020 less than body adequate swallow meals, swallowing process 1. Serving porridge, fish, vegetables, S:
requirements nutritional needs such as porridge, and ease the work of warm
associated with after nursing and serve while the stomach to - The client said there
nausea and actions for 3 days still warm digest food and 2. Encourage parents to give small was an appetite
vomiting, no with the meals but often
2. Instruct parents to avoid nausea O:
appetite, which is following 17.30 hours
provide food with 2. Because small - The food served
indicated by criteria: small portions but portions are usually 3. Record the number of servings of runs out ½ portion
DS: - The  child does frequent well tolerated. food that was consumed by ½ portion - Weight 25 kg
not feel nauseous techniques
- The  client said 19.00 hours
decreased appetite, and vomiting 3. Record the number 3. To determine the - Lips look dry
nausea and -  Increased of food servings 4. Encourage clients and parents to
amount of food A:
vomiting 2x appetite the client maintain oral hygiene by brushing
intake and Nutritional
consumes each day determination in the their teeth.
DO : -  Meals are up problems have not
4. Maintain patient next diet. 21.00 hours
-    M Akanan -  Weight gain been resolved
oral hygiene 5. Weighing body weight 25 kg 
presented not in again ½ kg 4. To stimulate P:
spend (only 5-6 5. Weigh body appetite 6. Explain to parents the benefits of
spoons) weight every day 5. To help with Continue nursing
nutrition for children, especially when intervention
- Now he is 25 kg 6. Explain to the nutritional status they are sick. must eat nutritious food
family the benefits 6.  Food is the addition to increase stamina and speed up the
- Lips look dry healing process
of food / nutrition of food for sick
for children, children 18.00 hours
especially when
they are sick Serving cefarox and starmuno drugs

3. Friday The potential for There was no 1. Monitor for signs 1.  To know if there are15.00 hours 22.00 hours
 bleeding further bleeding of bleeding signs of further 1. Monitor for signs of bleeding, namely
07/05/2020 associated with after 3 days of bleeding red spots, which appear on the skin S:
thrombocytopenia nursing action 2. To determine the 2. Monitor the number of decreased The client said
is a risk factor for with the 2. Monitor platelet
progress of the platelets 73.000 / dl  there were still red
further bleeding following drop
disease spots on both the
criteria: 15.30
- Parents say they feet and hands
3. Provides relaxation 3. Encourage children to rest a lot and
have red spots on - No red spots on 3. Encourage the for the limbs and O:
both feet and the skin reduce excessive activity because it
child to get plenty helps in the healing
hands will require more energy - There are red spots
- Platelets return to of rest process
- Looks red spots on normal, normal, 16.00 hours on the legs and
4. Helps increase the hands
the skin normal, 150,000-
4. Encourage children number of platelets 4. Encourage parents to give children
normal, 450,000 / drinking water / guava juice more - Platelets 61,000 / dl
- Platelets 73,000 / to drink lots of in the body
dl often, ± 1 glass / hour
dl water -        Hb : 15 gr%
5. Stimulate bleeding
- Normal 5. Encourage children not to brush their - Ht: 43%
- Leukocytes 1000 / by decreasing
leukocytes 6000- teeth hard because it will stimulate
dl platelet levels
12000 / dl 5. Instruct the child bleeding. A:
not to brush hard 6 .   Identify platelet
levels and provide 18.00 hours The potential
teeth  problem is
appropriate action so
6.  Collaboration with that further signs of 6. Take blood for Ht, Hb, platelets as bleeding
much as ± 2 cc
doctors for platelet bleeding can be not resolved
examination and anticipated 7. Serving trolit 1 sachet
therapy P:
Continue nursing
actions
4 Friday Changes in family The family shows 1. Assess the feelings 1. Because this usually 20.00 hours 22.00 hours
07/05/2020 processes positive coping and perceptions of happens in the 1. Asking and knowing the family's S:
associated with the behavior about parents or family adjustment process ability to threshold stress because the - Parents understand
child's condition their child after 2 members about and to strengthen client is being treated for the first time and understand
are characterized hours of nursing stressful situations family
 by action with the 2. Allow parents to understanding in the hospital O:
following express feelings
DS: 2. For families to 2. Allow the opportunity for parents to - The old man looks
criteria: and identify factors receive the support express feelings where the parents are calm
-  Parents wonder that are most
The client's they need so that worried because their child has not
about their child's worrying
parents are calm their ability to cope recovered how many times they have
illness.
and with problems can had their blood checked A:
DO : understanding be maximized 3. Knowing the coping of parents in The issue is
-  The parents are about the child's 3. To provide support dealing with problems so that they can resolved
disease and its 3. Identify coping
restless, and and calm as needed anticipate the situation by listening to P:
therapy. that can be used
pacing the room parents' complaints and providing
and how much Maintain nursing
explanations so that parents feel
success in actions
appreciated and anxiety can be
overcoming the
situation. 4. To provide optimal reduced or lost.
care for further
4. Ask the family intervention
what can be done
to make the child
or family better
off.
 BIBLIOGRAPHY

Arpenito, LJ 1999. Nursing Care Plans and Documentation. EGC: Jakarta

Doenges, Marlyn, 1989, Nursing Care Plans Second Edition, FA Davis Company,
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Bandung.
Wilson dan Thompson, J. M, Respiratory Disorder In Clinical Nursing Series, Mosby Year Book Inc.
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Suyono Slamet et al., 2001, Internal Medicine, FKUI Publisher Center, Jakarta.
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