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Asuhan Keperawatan DHF (Dengue Haemorhagic Fever)




ASUHAN KEPERAWATAN PADA ANAK DENGAN DHF
  1. Pengkajian
    Pengkajian merupakan tahap awal yang dilakukan perawat untuk mendapatkan data yang dibutuhkan sebelum melakukan asuhan keperawatan . pengkajian pada pasien dengan “DHF” dapat dilakukan dengan teknik wawancara, pengukuran, dan pemeriksaan fisik. Adapun tahapan-tahapannya meliputi :
    • Mengidentifikasi sumber-sumber yang potensial dan tersedia untuk memenuhi kebutuhan pasien.
    • Kaji riwayat keperawatan.
    • Kaji adanya peningkatan suhu tubuh ,tanda-tanda perdarahan, mual, muntah, tidak nafsu makan, nyeri ulu hati, nyeri otot dan sendi, tanda-tanda syok (denyut nadi cepat dan lemah, hipotensi, kulit dingin dan lembab terutama pada ekstrimitas, sianosis, gelisah, penurunan kesadaran).
  2. Diagnosa keperawatan yang Muncul
    1. Hipertermi berhubungan dengan proses infeksi virus dengue.
    2. Perubahan nutrisi kurang dari kebutuhan tubuh berhubungan dengan mual, muntah, tidak ada nafsu makan.
  3. Intervensi
    Diagnosa 1. :
    Gangguan volume cairan tubuh kurang dari kebutuhan tubuh berhubungan dengan peningkatan permeabilitas kapiler, perdarahan , muntah dan demam.
    Tujuan : Gangguan volume cairan tubuh dapat teratasi
    Kriteria hasil :
    • Volume cairan tubuh kembali normal
    Intervensi :
    • Kaji KU dan kondisi pasien
    • Observasi tanda-tanda vital ( S,N,RR )
    • Observasi tanda-tanda dehidrasi
    • Observasi tetesan infus dan lokasi penusukan jarum infus
    • Balance cairan (input dan out put cairan)
    • Beri pasien dan anjurkan keluarga pasien untuk memberi minum banyak
    • Anjurkan keluarga pasien untuk mengganti pakaian pasien yang basah oleh
      keringat.

    Diagnosa 2. :
    Hipertermi berhubungan dengan proses infeksi virus dengue.
    Tujuan : Hipertermi dapat teratasi
    Kriteria hasil :
    • Suhu tubuh kembali normal
    Intervensi :
    • Observasi tanda-tanda vital terutama suhu tubuh
    • Berikan kompres dingin (air biasa) pada daerah dahi dan ketiak
    • Ganti pakaian yang telah basah oleh keringat
    • Anjurkan keluarga untuk memakaikan pakaian yang dapat menyerap keringat seperti terbuat dari katun.
    • Anjurkan keluarga untuk memberikan minum banyak kurang lebih 1500 – 2000 cc per hari
    • kolaborasi dengan dokter dalam pemberian Therapi, obat penurun panas.

    Diagnosa 3. :
    Perubahan nutrisi kurang dari kebutuhan tubuh berhubungan dengan mual,
    muntah, tidak ada nafsu makan.
    Tujuan : Gangguan pemenuhan nutrisi teratasi
    Kriteria hasil :
    • Intake nutrisi klien meningkat
    Intervensi :
    • Kaji intake nutrisi klien dan perubahan yang terjadi
    • Timbang berat badan klien tiap hari
    • Berikan klien makan dalam keadaan hangat dan dengan porsi sedikit tapi
      sering
    • Beri minum air hangat bila klien mengeluh mual
    • Lakukan pemeriksaan fisik Abdomen (auskultasi, perkusi, dan palpasi).
    • Kolaborasi dengan dokter dalam pemberian Therapi anti emetik.
    • Kolaborasi dengan tim gizi dalam penentuan diet.
Sumber : http://kumpulan-asuhan-keperawatan.blogspot.com/2009/02/asuhan-keperawatan-pada-anak-dengan.html
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