Name Of Patient: Dennis Tubali Age: 30 y.

o Sex: Male

cc: pallor, dizziness Medical diagnosis: Dengue Hemorrhagic Fever Stage II; Typhoid Ileitis

Assessment Data Actual/Abnorma l cues:

Nursing Diagnosis

Rationale Typhoid Ileitis & DHF Viral infection Decreased CBC & platelet count Decreased level of hemoglobin and hematocrit

Ineffective Tissue Perfusion Subjective: r/t Decreased hemoglobin Dizziness Abdominal pain concentration in blood AEB low Muscle hemoglobin weakness concentration, pallor and Objective: dizziness, and Pallor muscle Hemoglobin = weakness. 63 g/L Hematocrit = 0.19 L/L Definition: Decrease in oxygen resulting in the failure to nourish the tissues at the capillary level [Tissue perfusion problems can exist without decreased cardiac output; however there may be a relationship between cardiac output and tissue perfusion.]
Source: Nurses Pocket Guide Ninth Edition

Nursing Nursing Objectives: Intervention After 32 hours of nursing intervention, my 1. client will be able 2. 1. a.) Encourage patient to take iron to: supplements and 1. Demonstrate eat foods rich in different ways iron. to improve b.) Elevate head of blood bed to about 10 oxygenation degrees. c.) Discourage and circulation.
strenuous activities.

Justification

Evaluation

1. a.)To help elevate hemoglobin and hematocrit levels b.) To promote circulation and venous drainage. c.)To avoid increased oxygen demand. 2. a.) To help client understand his health condition. b.)To maintain compliance to meds. 3. a.)Serve as basis for any alteration in system functions. b.) Enhances venous return. Help control/alleviate symptoms Maintain hydration and help wash away toxins Packed RBCs are adequate for stable patients with subacute/chronic bleeding to increase oxygen carrying capability. Aids in establishing blood replacement needs & monitorinf effectiveness of

2. Verbalize understanding Decreased blood of condition oxygenation and importance of treatment 3. a.) Monitor vital signs. pallor, dizziness, regimen. b.) Encourage early muscle ambulation when weakness 3. Demonstrate possible. increased tissue Collaborative: Ineffective perfusion. Administer tissue perfusion
medications as ordered Administer and regulate IVF as ordered Administer packed RBCs

2. a.) Provide health teaching regarding DHF and Typhoid Ilietis b.) Provide health teaching on drugs being taken.

Monitor lab studies ( Hb,Hct, RBC count)

Source:

Nursing Care Plan