ASSESSMENT

Subjective: Dumudugo ang Ilong ko. as verbalized by the patient. Objective: Weakness and irritability. Epistaxis. Abdominal distention with abdominal girth of (mild ascite) . Restlessness.

DIAGNOSIS
Injury, risk for hemorrhage related to altered clotting factor as evidenced by nose bleeding (epistaxis).

INFERENCE
Aedes Aegypti Dengue Virus IgG adheres to the platelet (initiates destruction of the platelet) thrombocytopenia (50,000/mm3 or less) Increased potential for hemorrhage (epistaxis) stimulates intense inflammatory response petechial rash, high fever, headache

PLANNING
After 8 hours of nursing interventions, the client will be able to demonstrate behaviors that reduce the risk for bleeding.

INTERVENTION
Independent: Perform thorough assessments regarding safety issues when planning for client care.

RATIONALE
Failure to accurately assess and intervene or refer these issues can place the client at needless risk and creates negligence issues for healthcare practitioner. The G.I tract (esophagus and rectum) is the most usual source of bleeding of its mucosal fragility. To minimize the amount of blood pressure on nasal vessels and to keep blood moving forward, not back to the nasopharynx. To minimize or stop bleeding.

EVALUATION
After 8 hours of nursing interventions, the client where able to demonstrate behaviors that reduces the risk for bleeding. The goal is met.

Assess for signs and symptoms of G.I bleeding. Check for secretions. Observe color and consistency of stools or vomitus. Position the client on upright position with head tilted slightly forward.

Using your fingers apply pressure to the sides of the nose. Apply nasal pack or cold compress. Observe for presence of petechiae,

To minimize or stop bleeding. Sub-acute disseminated intravascular

ecchymosis, bleeding from one more sites.

coagulation (DIC) may develop secondary to altered clotting factors. An increase in pulse with decreased Blood pressure can indicate loss of circulating blood volume. Changes may indicate cerebral perfusion secondary to hypovolemia, hypoxemia. Rectal vessels are most vulnerable to rupture. In the presence of clotting factor disturbances, minimal trauma can cause mucosal bleeding. Minimizes damage to tissues, reducing risk for bleeding and

Monitor pulse, Blood pressure.

Note changes in mentation and level of consciousness.

Avoid rectal Temperature.

Encourage use of soft toothbrush, avoiding straining for stool, and forceful nose blowing. Use small needles for injections. Apply pressure to venipuncture sites for longer than

usual.

hematoma.

Recommend Prolongs avoidance of aspirin coagulation, containing products. potentiating risk of hemorrhage. Dependent: Administer medications and infusions as prescribed and by using 5 rights system (right patient, right medication, right route, right dose,right time) Interdependent: Monitor Hb and Hct and clotting factors. To treat the underlying cause of the disease.

Indicators of anemia, active bleeding, or impending complications.

ASSESSMENT
Subjective: Nilalagnat at nanghihina po ako. as verbalized by the patient. Objective: Weakness and irritability. flushed skin Warm to touch. Febrile Restlessness. Temperature taken as follows: T: 38 C

DIAGNOSIS
Altered body temperature rated to altered clotting factor as evidenced by a temperature of 38C.

INFERENCE
Aedes Aegypti Dengue Virus IgG adheres to the platelet (initiates destruction of the platelet) thrombocytopenia (50,000/mm3 or less) Increased potential for hemorrhage (epistaxis) stimulates intense inflammatory response petechial rash, high fever, headache

PLANNING
After 8 hours of nursing intervention the patient will be able to maintain core body temperature within normal range.

INTERVENTION
Independent: Establish rapport with the patient and patients relative Note chronological and developmental age Monitor temperature Monitor BP

RATIONALE
To gain the trust and cooperation Children are more susceptible to heatstroke To have baseline data.

EVALUATION
After 8 hours of nursing intervention the patient where able to maintain core body temperature within normal range. Temperature of 36.7.

Central Goal is met. hypertension or peripheral/postural hypotension may occur. Dysrhythmias and ECG changes are common. Hyperventilation may be present. Evaporation is decreased by environmental factors of high humidity. To prevent dehydration. To promote heat loss by evaporation and conduction. To promote heat loss by radiation

Monitor heart rate and rhythm.

Monitor respirations Note presence or absence of sweating

Advise increase fluid intake. Encourage TSB.

Loosen clothing

and conduction. Provide cool environment and/or fan. Put local ice packs or wet towels areas of high blood flow, especially groin and axillae. Provide hypothermia blankets. Maintain bed rest To promote heat loss by convection. To promote heat loss.

To minimize shivering. To reduce metabolic demands/oxygen consumption. For baseline data. To lower temperature.

Monitor and record I and O Dependent: Administer meds as ordered, antipyretics and/or antibiotics. Administer fluid replacement as indicated by the physician. Interdependent: Provide highcalorie diet, tube feeding, parenteral nutrition.

To support circulating volume and tissue perfusion. To meet increased metabolic demands.

ASSESSMENT
Subjective: Lumalaki ang tiyan ko. Dumugo rin po ang ilong ko. as verbalized by the patient. Objective: Weakness and irritability. flushed skin Warm to touch. Febrile Restlessness. Blood Pressure taken as follows: BP: 100/80 mmhg

DIAGNOSIS
Risk for deficient fluid volume related to decreased blood volume secondary to altered platelet production.

INFERENCE
Aedes Aegypti

PLANNING

INTERVENTION
.

RATIONALE

EVALUATION

Dengue Virus IgG adheres to the platelet (initiates destruction of the platelet) thrombocytopenia (50,000/mm3 or less) Increased potential for hemorrhage (epistaxis) stimulates intense inflammatory response petechial rash, high fever, headache