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NCP Dengue

NCP Dengue

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Published by Yeana Alon

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Published by: Yeana Alon on Jun 30, 2010
Copyright:Attribution Non-commercial

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08/21/2013

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Name Of Patient:
Dennis Tubali
cc:
pallor, dizziness
Age:
30 y.o
Medical diagnosis:
Dengue Hemorrhagic Fever Stage II; Typhoid Ileitis
Sex:
Male
 
AssessmentDataNursingDiagnosisRationaleNursingObjectives:NursingIntervention JustificationEvaluationActual/Abnormal cues:Subjective:
Dizziness
Abdominal pain
Muscleweakness
Objective:
Pallor
Hemoglobin =63 g/L
Hematocrit =0.19 L/LIneffective Tissue Perfusionr/t Decreasedhemoglobinconcentration inblood AEB lowhemoglobinconcentration,pallor anddizziness, andmuscleweakness.
Definition:
Decrease inoxygen resultingin the failure tonourish thetissues at thecapillary level[Tissueperfusionproblems canexist withoutdecreasedcardiac output;however theremay be arelationshipbetween cardiacoutput andtissueperfusion.]
Source:
Nurse’s PocketGuide Ninth Edition
 Typhoid Ileitis &DHFViral infectionDecreased CBC& platelet countDecreased levelof hemoglobinand hematocritDecreased bloodoxygenationpallor, dizziness,muscleweaknessIneffectivetissue perfusionAfter 32 hoursof nursingintervention, myclient will be ableto:1.Demonstratedifferent waysto improvebloodoxygenationand circulation.2.Verbalizeunderstandingof conditionandimportance of treatmentregimen.3.Demonstrateincreasedtissueperfusion.
1.2.1. a.) Encouragepatient to take ironsupplements andeat foods rich iniron.b.) Elevate head of bed to about 10degrees.c.) Discouragestrenuousactivities.2. a.) Provide healthteaching regardingDHF and TyphoidIlietisb.) Provide healthteaching on drugsbeing taken.3.a.) Monitor vital signs.b.) Encourage earlyambulation whenpossible.
Collaborative:
Administermedications asordered
Administer andregulate IVF asordered
Administer packedRBC’s
Monitor lab studies( Hb,Hct, RBC count)
Source:
1.a.)To helpelevatehemoglobin andhematocrit levelsb.) To promotecirculation andvenous drainage.c.)To avoidincreased oxygendemand.2. a.) To help clientunderstand hishealth condition.b.)To maintaincompliance tomeds.3.a.)Serve asbasis for anyalteration in systemfunctions.b.) Enhances venousreturn.
Helpcontrol/alleviatesymptoms
Maintain hydrationand help wash awaytoxins
Packed RBC’s areadequate for stablepatients withsubacute/chronicbleeding to increaseoxygen carryingcapability.
Aids in establishingblood replacementneeds & monitorinf effectiveness of 

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