NURSING CARE FOR Mr.

K
WITH DENGUE HEMORRHAGIC FEVER
ANGGREK ROOM TPT HOSPITAL

Supporting Lecture:
Ahmad Widhoni,.S.Pd

CREATED BY:

FITRI HANDAYANI 144012252

NURUL WIJAYANTI 144012266
WAYAN DANI KARINA 144012279
TRI WIDYA SAFITRI 144012278

POLITEKNIK KESDAM VI
BANJARMASIN

PRODI DIII KEPERAWATAN

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.

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
Do: The client's clothes that can temperature and
feels hot avoid other diseases
body is not hot absorb sweat
 TTV.TD:120/80m 4. Collaboration 4. To replace the
mhg in the liquid that comes out
R: 16-20x / minute administration of of sweat and reduce
N: 80-100x / minute drug and fluid heat
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 able 3. 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

Risk deficit after nutrition Carried out action

Nutrition
proven with no ability to nursing for 3x24 hours
digest food then the status nutrition management:
improves with 2 result Observastion :
criteria:
1. meal portions: 1.identfy
Spent of decreased to nutritional status
quite increased
2. verbalize desires 2.monitor food
Increase nutritional from intake
decreasing become just
increased 3. monitor body
3.the feeling of fullness weight
quickly increases to
quite desreased Therapeutic
4.appetite from worse to
getting quite better 1.serve food
5.mucous membranes attractively and
from deteriorating to at the
 quite improved
6.body weight from
appropriate
moderately decreased to 2.give higt food
moderately increased
to fiber
Education:
1.teach a
programmed
which diet
2.suggest a
sitting
position ,If
necessary
Collaboration:
1.collaboration
administration of
medication
before meals(eg
pain
relievers ,antibio
tic ),if necessary.

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

fulfillment of 120/70 mmhg R: still feels nauseous
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

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

increasing body temperature
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

09:00 Risk desicir Nutrition S:the client said no

nutrition proven appetite
mamnagement :
wqith no ability -client says he doesn’t
digest food 1.identify nutritional
finish his portion of
status food
Result : -client says he feels
-the client said that quickly when eating
before he was -client says he vomits
when eating client
sick ,the client ate
09:10 -says he feels nauseous
the first portion of -client says he wants to
food ,whereas when increase nutritional
he was sick ,the intake
portion of food he
ate was not finished
2.monitor intake O:client appears weak
09:15 On food -dry lips
The result is that -anemic conjungctiva
-BP:110/80 mmHg
The client does not
-N:83 xminute
Finish his food RR:22 x minute
3.monitor body BB after illness
weight. 55 kg
Result :at the time BMI:22.9
BB before lllness :58 kg
09:20 of illness ,body IMT:24.1
weight was 55 kg A:the problem has not
4.provide been resolved
Foods hight in fiber P:interentions 1,2,3,4,5
and 6 continue
the : of the vegetable
food menu. Given
there were vegetable
an soup bu the client
didn’t want it eat
5.serve food
09:25
attractively and at
the appropriate
temperature
the:result of the
 client trying to eat
when the food given
is warm,provides
food
09:40 6.teach diet
programmed
Result:clent
understand and want
do
7.teach position sit
down if needed
client sitting result
09:45
when going to eat
8.colloboration
administering
medication before
eat (eg.pain reliever
antibiotic ). If need
result:drug
ondansetron ,omepr
10:00
azole.