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Ncp for Dengue

Ncp for Dengue

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Published by Pamela Ann Perez

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Published by: Pamela Ann Perez on Jul 02, 2012
Copyright:Attribution Non-commercial

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03/03/2014

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Assessment Diagnosis Planning Inference Implementation Rationale Evaluation
 
Subjective
“Ang init init ng
kapatid kokapag
hinahawakan”
As verbalized
 by the patient’s
sister.
 
Objective-
 
V/S taken asfollowsT- 38 degreecelciusPR- 88 bpmRR-22 cpmBP-110/70mmHg-
 
Flushed skin-
 
Warm totouchHyperthermiarelated toinappropriateclothingfactor asevidencedby decreasein plateletcount secondaryto denguehemorrhagicfever.After 2 hoursof nursinginterventionclient will beable tomaintain coretemperaturewithin normalrange asevidenced by:- bodytemperature islowered to 37degree celcius.Body temperatureelevated abovenormal level that isusually caused byseveral factorsrelated to illness.As inoculationoccurs, proliferationof virus follows andonce the virus startsto grow in number,it will soon reachit pathogenic levelthat will resultinto pyrexia orfever as a defensemechanism of thebody.Reference:
 Nurse’s
pocket guide byMarilynDoeges10th editionIndependent:- Provide tepidsponge bath-Promote surfacecooling by meansof undressing- Provide coolenvironment-Maintain bedrest or minimizemovement- Discussimportanceof adequate fluidintake particularlyto the parents.-
 
Strictly monitortemperature-Heat loss bymeansof evaporationand conduction.-Heat loss bymeansof radiation andconduction-Heat loss bymeansof convection- To reducemetabolicdemands of oxygenconsumption- To preventdehydration-
 
To know if the
 patient’s
temperaturewent down tothe normalAfter 4 hours of nursinginterventiongoals andobjectives wasmet asevidenced by:-Bodytemperaturelowered to 37degree celcius.
 
 -Increase fluidintakeDependent:Administerparacetamol asprescribed by thephysician.Collaborative:Refer to thephysician if thetemperature stillhigher to normalrange.value.-
 
To lower thetemparature-
 
To alleviatethe fever of thepatient.-
 
To monitor
 patient’s
condition.
 
Assessment Diagnosis Planning Inference Implementation Rationale Evaluation
 
Subjective
“Dumudugo
yung labi ng
kapatid ko”
Asverbalizedby the
 patient’s
sister
 
Objective-Weakness andirritability-Restlessness-V/S taken asfollows:T- 38.1PR- 90 bpmR- 22 cpmBP- 110/70mmHgRisk forhemorrhagerelated toaltered clottingfactor.-After 3 hours of nursinginterventions, the clientwill be able todemonstrate behaviorsthat reduce the risk of bleedingMost dengueinfectionsresult inrelativelymild illness,but some canprogress todenguehemorrhagicfever. Withdenguehemorrhagicfever, theblood vesselsstart to leak and causebleeding fromthe nose,mouth, andgums.Bruising canbe a sign of bleedinginside thebody.Withoutprompttreatment, theblood vesselscan collapse,causing shock (dengue-Assess the signs andsymptoms of GI bleeding.-Check for secretions.-Observe color andconsistency of stoolsor vomitus.-Observe forpresence of petichiae,ecchymosis, bleedingfrom one more sites.-Monitor pulse, BP-Note changes inlevelof consciousness.-Encourage use of soft toothbrush.Avoid straining instool, and forcefulnose blowing.-The GI tract is themost usual sourceof bleeding of itsmucosal fragility-Sub-acutedisseminate dintra-vascularcoagulation maydevelop secondaryto altered clottingfactor.-An increase inpulse with decreaseBP can indicateloss of circulatingblood volume-Changes mayindicate cerebralperfusion problems.-Minimal traumacan cause mucosalbleeding-After 3 hoursof nursinginterventions, theclient
’s
sister is able todemonstrate behaviorsthat reduce the risk of bleeding.

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