A.

ASSESSMENT
1. identity
Name: An. E.C
Age: 9 years
Address: Embankment Asri 23/27 Surabaya
Religion: Christian
Mother's Name: Mrs.. T
education:
Father's Name: Mr. S
Education: High School
Occupation: Private
Diagnostic Medical: DBD Grade II
Assessment date: December 13, 2001

B. Main complaints:
Headache, hot and no appetite.

C. History of present illness:

Monday morning heat, paracetamol can be taken to the health center. Heat
down. Wednesday night children suddenly vomited water, would not eat,
drink still going. Thursday at 03 am the blood out of hiding at the time of
sneezing, complaining of dizziness, diarrhea water, brought to the IRD.

D. Past medical history

Previous clients have always been treated for any disease.

E. Family history of disease

According to the family (Mother) no family in the near future dengue
illness.
F. Environmental health history.
According to the mother's home environment clean enough, despite living
near a small time, around the house there are some old tires to grow plants
that have not been used, the tub drained every week 1 time. According to
the mother a week ago there were neighbors who suffer from DHF alley,
but has now recovered, and the environment have not been sprayed areas.

G. history of pregnancy
Children born at 7 months gestation, with a birth weight of 4 kg, the
mother did not know why only 7 months pregnant. Spontaneous birth and
during the first year children immunized and drinking PASI complete
Lactona s / d 2 years.

H. assessment system
a. Gastrointestinal system
Decreased appetite, kids just want to eat 3 tablespoons, drinking did not
like, was going to be forced to drink. No nausea, no vomiting occurred.
There is tenderness and ascites liver area positive bowel sounds 8x/mnt.
b. Musculoskeletal system:
There were no joint contractures, no deformity, four extremities
symmetrically, good muscle strength.
c. genitourinary system
BAK fluent, spontaneous, rather thick yellow accommodated by the
mother to be measured, there is no Chapter of the night.
d. Respiration system.
Symmetrical movement of breath, nostril breathing terdapt not, at the
moment the signs of epistaxis assessment is not there, breathing frequency
25x/menit. Additional breath sounds are not audible.
 e. cardiovascular system
BP: 100/60, pulse 98x/mnt, akral cold, there are no signs of cyanosis, cap.
Refill <3 seconds, no spontaneous bleeding, signs of spontaneous petikhie
not visible, only sign the former pethike rumple leed.
f. Neurosensori system
No abnormalities.
g. Endocrine system
No abnormalities.
h. Integumentary system.
S: 376 good turgor, no injuries, the former pethikae rumple leed, there is
no spontaneous bleeding of the skin.
I. examination Support
Hb: 11.8
Leko: 5.5
Trombo: 133
PCV: 0,30
J. therapy
Infusion D ½ saline 1.6 thousand cc/24 hour
drinking sweet
Vit B compleks / C 3 x 1
Diet TKTP 1.6 thousand Kkal + 50 gr Protein.
rice 3 x a day
Milk: 3 x 200 cc
1. ANALISA DATA
No Supporting Data Etiologi Problem
S1 : S: S: The client said body hypertermi
feel hot, dizzy The process of dengue virus
O: Akral cold infection
2 long hot day. Ô
TTV: S: 376, Nadi viremia
98x/mnt, BP: 100/60, RR Ô
25x/mnt. thermoregulation

2 S: Clients say do not like Increased body temperature body fluids

drinking and stomach feel Ektravasasi fluid
full drinking continues. intake less
O: good skin turgor Ô
Mucosal dry lips Plasma volume decreases
Lots of dark yellow urine Ô
2 long hot day Decrease in body fluid
Platelets; 133,000 volume
BP: 100/60, N; 98x/mnt.

3 S: Client states do not Nutrition

want to eat, but not Decreased appetite
nausea. Ô
O: KU weak Inadequate nutrient intake
Breakfast only want 3 Ô
scoops Nutrition less than body
requirements
2. Nursing Diagnosis
1. Increase in body temperature associated with dengue virus infection
process.
2. Risk of fluid volume deficit related to migration of intravascular fluid into
the extravascular
3. Less risk of nutritional deficiencies associated with a decreased appetite.

3. Planning
1. Increase in body temperature associated with dengue virus infection process
Objective: Body temperature returned to normal
Criteria: TTV particular temperature within normal limits (365-375)
Mucous membranes moist.
Intervention Plan;
1. TTV observations every 1 hour
Rational: Determining the subsequent intervention when changes
2. Provide regular water compress / faucet
Rational: Compress will provide induction heat expenditure.
3. Encourage clients to drink plenty of 1500 - 2000 ml
Rational: Replacing body fluids that come out because of the heat and spur
spending lewt urine urine for heat dissipation.
4. Suggest to wear thin clothes and stinging sweat.
Rational: Providing a sense of comfort and magnify heat evaporation
5. Observation intake and out put
Rational: Detection of the lack of body fluid volume.
6. Collaboration for antipyretic administration
Rational: Antipireik useful for heat reduction.

2. Risk of fluid volume deficit related to intravascular fluid into the

extravascular emigration.
Objective: Not happening hypovolemic shock
Criteria: BP 100/70 mmHg, N: 80-120x/mnt
strong pulsation
akral warm
Intervention Plan;
1. Vital sign observation every hour or so.
Rational: Knowing the condition and identify fluctuations in intra-vascular
fluid.
2. Observation of capillary refill
Rational: Indications adequacy of peripheral circulation.
3. Observation of intake and output, record the number, color / urine
concentration.
Rational: Decrease in urine output / urine is concentrated to increase BJ
suspected dehydration.
4. Encourage your child to drink 1500-2000 ml
Rational: To meet the needs of the body ciran
5. Collaboration of intravenous fluids or plasma or blood.
Rational: Increase the amount of fluids to prevent hypovolemic shock.

3.Less risk of nutritional deficiencies associated with a decreased appetite.

Objective: Nutrition fulfilled
Criteria: increased appetite
Spent portions
Intervention Plan:
1. Assess complaints of nausea, vomiting, or decreased appetite
Rational: Determining interventions.
2. Provide easy to swallow food easily digested
Rational: Reduce fatigue and prevent gastrointestinal bleeding clients.
3. Give small meals but often.
Rational: Avoiding nausea and vomiting
4. Avoid stimulating foods: spicy, sour.
Rational: Prevent the occurrence of distension of the stomach that can
stimulate vomiting.
5. Give clients favorite food
Rational: Allows inclusion of more
6. Collaboration of parenteral fluids
Rational: Parenteral nutrition is necessary if oral intake is very less.
 NURSING CARE OF CHILDREN E
WITH DHF
IN THE EDELWEISS HOSPITAL DR. M. YUNUS BENGKULU

GROUP II :

1. ADIMAN

2. AHMAD SYAFIATUDIN

3. DEKA OKTARI

4. RYAN TAGOR

5. TRIO RIDHO A

6. YUNITA HARTATI

POLITEKNIK KESEHATAN PROVINSI BENGKULU

JURUSAN KEPERAWATAN

TA 2012/2013