Nursing Care Plan for Dengue Hemorrhagic Fever
Nursing Diagnosis : Fluid Volume Deficit related to Active Fluid Loss
Defining characteristics:
- Changes in mental status.
- Decreased blood pressure.
- Decreased pulse pressure.
- Decreased pulse volume.
- Decreased skin turgor.
- Decreased turgor tongue.
- Spending urine output.
- Decrease venous filling.
- Dry mucous membranes.
- Dry skin.
- Increased hematocrit.
- Increased body temperature.
- Increased pulse frequency.
- Increasing the concentration of urine.
- Weight loss suddenly.
- Thirsty.
- Weakness.
Goal: Do not occur voume fluid deficit.
Outcomes:
- Input and output balance.
- Vital signs within normal limits.
- There is no sign of pre-shock.
- Akral warm.
- Capilarry refill less than 3 seconds.
Intervention:
1. Monitor vital signs every 3 hours / more often.
Rationale: Vital sign help identify fluctuations in intravascular fluid
2. Observation of capillary refill.
Rationale: Indications adequacy of peripheral circulation.
3. Observations intake and output. Note the color of urine / concentration, specific gravity.
Rationale: Decreased urine output with increased density concentrated suspected dehydration.
4. Suggest to drink 1500-2000 ml / day (as tolerated)
Rationale: To consume body fluids orally.
5. Collaboration: intravenous fluid administration.
Rational: It can increase the amount of body fluid, to prevent hypovolemic shock.