Miss A (4 YO) was admitted to the health clinic by her mother with complaints of fever,

headache, cold, and nose bleed. Her mother stated that Miss A has got the fever for 5
days, and has been brought to the doctor before. The doctor prescribed pulvis but the fever
was still unstable. The assessment data showed that her T: 39⁰C , P: 100 bpm, RR: 24
breath/minute, weight: 18.5 kg, height: 123 cm, reddish skin, petechiae (+), Hb 10.5
mg/dl, and warm extremity. Her mother said that Miss A was fussy and difficult to sleep

Miss A (4 YO) dirawat di klinik kesehatan oleh ibunya dengan keluhan demam, sakit
kepala, pilek, dan hidung berdarah. Ibunya menyatakan bahwa Nona A menderita demam
selama 5 hari, dan telah dibawa ke dokter sebelumnya. Dokter meresepkan pulvis tetapi
demamnya masih tidak stabil. Data penilaian menunjukkan bahwa T: 39⁰C, P: 100 bpm,
RR: 24 napas / menit, berat: 18,5 kg, tinggi: 123 cm, kulit kemerahan, petechiae (+), Hb
10,5 mg / dl, dan ekstremitas hangat. Ibunya berkata bahwa Nona A rewel dan sulit tidur

OUTLINE OF NURSING CARE PLAN 2020

TITLE : Nursing Care Plan of Mr./Mrs./Ms. A

A Patient with Dengue Fever (Medical Diagnosis)

A. IDENTITY
Patient’s Identity : Miss A
Age : 4 YO

B. CASE REVIEW
1. Chief Complaint :
- Fever has been up and down 5 days
2. History of Present Illness
- Of Fever,
- Headache,
- Cold,
- And Nose Bleed
3. Past Medical History
- There is no
4. Family History
- There is no
5. Physical Examination
- T: 39⁰C
- P: 100 bpm
- RR: 24 breath/minute
- weight: 18.5 kg
- height: 123 cm
- reddish skin
6. Additional Data
- petechiae (+)
- Hb 10.5 mg/dl
- and warm extremity
C. DATA ANALYSIS
1. Data Clustering
No. Date Focus Data Problem Etiology
1. SD: Hyperthermia Due to an increase in
- Her mother stated metabolism which is
that Miss A has got the marked by a decrease
fever for 5 days, and in hemoglobin
has been brought to the
doctor before
- The doctor prescribed
pulmonary but fever is
still unstable.

OD: - T: 39⁰C,
- Hb 10.5 mg/dl
- reddish skin
- warm
extremity
2. SD : Disorders of comfort abnormal
- Her mother said that (sleep rest) physiological status is
Miss A was fussy and characterized by a high
difficult to sleep body temperature and
blood coming out of
OD :
the nose, headaches,
- High fever T :39⸰C colds
- Nose bleed
-Headaches
- Colds

2. Nursing Diagnosis and Problems Priority

1) Hyperthermia is associated related to increased metabolism
2) Comfort disorders (sleep rest) are associated related to abnormal
physiological status
D. NURSING OUTCOME
No. Nursing Diagnosis Expected Outcome Rationale
1 1) Hyperthermia is After taking nursing - Not reporting
associated related actions for 2x24 hours the temperature fluctuation
to increased patient is expected to (unstable)
overcome thermogulation - HB has started normally
metabolism
with the results of the - skin color returned to
following criteria: normal
Thermoregulation :

- Temperature 36-37 ° C
- Normal HB 11.5-13.5 g /
dL
- There is no change in
skin color and no dizzines
2 1) Comfort After doing nursing -set the child's sleep time
implementation for 2 x
disorders 24hours, the client will so as not to fatigu
(sleep rest) achieve sleep (0004) as
 are evidenced by: -to restore the lost energy
associated 1. Hours of sleep after crying all da
2. Sleep patterns -in order to quickly restore
related to 3. Feeling refreshed after
the bod
abnormal sleeping
physiologi 4. Sleep from the
cal status beginning to the end at
night consistently

E. NURSING INTERVENTION
No. Expected Outcome Nursing Intervention Rationale
1 After taking nursing - Temperature monitoring -To prevent patient
actions for 2x24 hours the as often as possible development with warm
patient is expected to - Do a warm compress compresses can reduce
overcome thermogulation - Suggest wearing thin patient's body
with the results of the clothes temperature to return
following criteria: - Give intravenous fluids normal
Thermoregulation : - Monitor HB - Maintain a balance of
- Temperature 36-37 ° C - Monitor skin color and body fluids and replace
- Normal HB 11.5-13.5 g / temperature fluids lost due to
dL - Give anti-pyreti hyperthermia
- There is no change in - By giving this drug can
skin color and no dizzines neutralize the body heat
and help antibodies
against infection
- Keep monitoring HB
- Monitor skin color so
that it returns to norma
2 Sleep Improvement (1850)
 Teach patients and people closest regarding
factors who contributed pattern disturbance sleep (for example, physiological, psychological
-Teach his mother how do muscle relaxation autogenic or non-form other pharmacology for
sleep fishing.
- Start / apply steps - such comfort steps massage, positioning, and affective touch
RASIONAL
- Provides basic information in determining the plan care.
- Give a sense of comfort and speed up the sleep process
- Improve sleep patterns.