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1 Hyperthermia Assessment S>ø O> patient manifested: >Flushed warm skin >Increase Temp. of 38.5 C >irritability >Diaphoresis patient may manifest:
Nursing Diagnosis Hyperthermia related to inappropriate clothing factor as evidenced by decrease in platelet count.
Scientific explanation Dengue Hemorrhagic Fever is potentially deadly complication that is characterized by high fever. Hyperthermia is an abnormal rise in the temperature of the human body. Normal body temperature is 98.6 F or 37.5
Objectives Short term: After 4 hours of Nursing Interventions the patient’ will be maintaining a normal body temperature.
Interventions >Establish good working condition with the pt and SO. >monitor v/s q 2hours. >provide TSB
Rationale >to gain patient’s trust
Expected Outcome Short term: The patient’s body temperature shall have a
>to have baseline data >to maintain a normal body temperature.
maintained normal body temperature.
Long Term: After 4 days of NI, the patient will experience no associated complications such as seizures etc. >Encourage food rich in Vitamin C >to boost body resistance to infection >Encourage increase fluid intake >to replace fluid loss Long Term: After 4days of NI, the patient will experience no associated complications such as seizures
Increased PR Increased RR Seizure Muscle rigidity
C. Fever may
not result only from a disturbance of
heat-regulating mechanism of the body but also through disturbances of the blood. 2 ineffective tissue perfusion related to decrease hgb concentration . Indeed there are oral intake during periods of illness will result to further body weakness impairing the patient’s ability to perform usual routines and ADL’s >provide client safety >to prevent further injuries etc. the rate of breathing. >maintain bed rest >to preserve energy Problem No.
effective treatment >loss of peripheral pulses must be reported or . the patient shall have demonstrated increase tissue perfusion AEB normal Hgb level count Long Term: After 2-3 days of NI. This was manifested through flushed palms and soles and appearance of brownish purplish rashes on the Objectives Short term: After 3 hours of Nursing Interventions the patient’ will demonstrate behaviors that will improve thee tissue perfusion. Interventions > Establish good working condition with the pt and SO >Assess the patient’s condition > Monitor vital signs Rationale >to gain patient’s trust Expected Outcome Short term: After 3 hours of Nursing Interventions the patient shall >to have baseline data have demonstrated behaviors that will improve thee >needed for ongoing comparison tissue perfusion.Assessment S>ø O> patient manifested: >appears pale and weak >flushed palms and soles Nursing Diagnosis ineffective tissue perfusion related to decrease hgb concentration Scientific explanation Due to the replication of dengue virus in the body. there could be stimulation of production of kinine causing increase vascular permeability leading to capillary damage. Thus will cause internal bleeding. the patient will demonstrate increase tissue perfusion AEB normal Hgb level count >assess for possible causative factors r/t temporarily impaired arterial blood flow >Monitor quality of all pulse >early detection of cause facilitates prompt. Long Term: After 2-3 days of NI.
extremities treated immediately >maintain optimal cardiac output >review lab values and note customary baseline data >to increase cellular oxygen supply >to evaluate the importance of NI’s given and provide comparison by current findings Problem # 3: Risk for injury r/t abnormal blood profile as evidenced by decrease platelet count Assessment Nursing Diagnosis Scientific explanation Objectives Interventions Rationale Expected Outcome .
prevent falls) > Observe for each stool color. lifestyle changes to risk factors and protect self. the patient’ will be free from injury. >Establish rapport >to gain patient’s trust Short term: After 4 hours of Nursing Interventions. pt will demonstrate techniques behavior. When the blood vessels are cut or damage . side rails. ‘s ability to protect self and comply with required self protective actions Low platelet count Abnormal blood profile Tissue Hypoxia Pt may manifest Sensory dysfunction Broken Skin Malnutrition >Provide safe environment (pad. lifestyle changes to risk factors and protect self. Risk of Injury as a result of environmental conditions interacting with the individuals adaptive and defensive resources.S>ø O> patient manifested the following which put his at risk for injury Risk for injury r/t abnormal blood profile as evidenced by decrease platelet count. Long Term: After 1 days of NI. consistency and amount >Observe for > Minimizes injury to occur After 1 days of NI. the the patient’ will have been free from > Permits detection of bleeding in GI tract > Indicate injury. . pt will have demonstrate techniques behavior. the loss of blood from the system must be stop before shock and possible Short term: After 4 hours of Nursing Interventions. It is also because of the infection of DHF I Virus that destroys the platelets which place the patient at risk of bleeding. Long Term: >Assess level of consciousness and cognitive level >assist in determining pt.
. and bleeding gums altered clotting mechanism >Encourage intake of foods with high content of Vit. hemorrhagic manifestation. > Provide comfort measures. there is a danger of uncontrolled bleeding because of the essential role that platelets have in blood clotting. epistaxis. a process called coagulation or clotting. This is accompanied by solidification of the blood. If the value should stop below normal.death may occur. ecchymosis. (150. such as stretching bed > To obtain baseline data > To promote relaxation and alleviate .000 g/dl). Petechiae. C > Promotes healing and boost the resistance of the body against infection > Assess pt’s condition and monitor vital signs.000 -450.
linens. > Avoid SC. IM route of injection as possible > Minimizes tendency of trauma or bleeding .
It may also cause infection which may lead to constipation After 3 hrs of nursing interventions patient will demonstrate behaviors changes to developing problem Provide comfort measures by AM care.Problem # 4: Risk for constipation related to irregular defecation habits as evidence by defecate once or twice per week Assessment S=Ø Risk for O= patient manifested by: irregular defecation habits inadequate toileting recent environmental changes >change in usual eating pattern >ignoring urge to defecate After 2 hrs of nursing interventions patient will Patient may manifested by: improve her bowel pattern Provide safety by placing pillows at the side of the bed To avoid patient from injury LT: constipation related to irregular defecation habits as evidence by defecate once or twice per week Irregular defecation habits of one or two times per week may cause the stool to harden and dry. changing the linen and touch therapy For proper hygiene of the patient Patient shall have improve her bowel pattern LT ST Provide comfortable environment To ease patient’s anxiety and to help the patient recover faster for proper hygiene of the patient Patient shall have demonstrate behavior changes to developing problem ST Nursing Diagnosis Scientific explanation Objectives Interventions Rationale Expected Outcome .
location and characteristics of bowel sounds Reflecting bowel activity VS monitor and change To have baseline data Review medication For impact effect of change in bowel function Encourage balance fiber and bulk habit To improve consistence of the stool and facilitate passage through colon . >dehydration >electrolyte imbalance >decrease motility of gastro intestinal troat >hemorrhoids Insufficient physical activity Auscultate abdomen for presence.
Promote adequate fluid intake. promotes recognition of changes Educate client/SO about safe and risky practice for managing constipation Information can help client to make beneficial choices when needed . amount of stools Provide as baseline of comparison. consistence. also suggest drinking warm fluid To promote soft stool and stimulate bowel activity Ascertain frequency. color. including water and highfiber fruit juice.
secondary to haematoma as evidence by collection of blood on the upper extremities. Discuss client’s current medication regimen with physician To determine if drugs contributing to constipation can be discontinue or change Problem # 5 Impaired tissue integrity related to mechanical and chemical factor of IV infusion and blood test. Nursing Scientific Expected .Review medical/ surgical history To identify condition commonly associated with constipation Review appropriate use of medication.
secondary to haematoma as evidence by collection of blood on the upper extremities. In minor injuries. Explanation Hematoma is a localized collection of blood.Assessment S=Ø O= patient manifested by: pallor haematoma on both upper extremities weakness impaired circulation damage tissue Diagnosis Impaired tissue integrity related to mechanical and chemical factor of IV infusion and blood test. usually clotted. changing the linen and touch therapy For proper hygiene of the patient Provide safety by placing pillows at the side of the bed Encourage adequate periods of rest and sleep To avoid patient from presence of injury haematoma Patient may manifested by: fluid deficit infection acute pain change in turgor edema To limit metabolic demands. in a tissue or organ. the blood is absorbed unless infection develops. maximize energy and meet comfort needs VS monitor and To have baseline . One of the signs of haematoma is collection of blood in the peripheral area it may be seen in the upper extremities. Hematomas can occur almost anywhere on the body. Mechanical and chemical factors like IV infusion Objectives ST After 4 hrs of nursing interventions patient will demonstrate behavior to reduce the hematoma LT After 2 weeks of nursing interventions presence of hematoma will be reduce Interventions Provide comfortable environment Rationale To ease patient’s anxiety and to help the patient recover faster for proper hygiene of the patient ST Outcome Patient shall have demonstrate behavior to reduce hematoma LT Patient shall have reduce Provide comfort measures by AM care.
bony prominences. for change Monitor laboratory studies To comparative baseline Promote timely interventions/revision of plan of care To changes indicative of healing or infection complications .and blood test may cause haematoma. pressure areas and wounds Inspect lesions/wounds daily. desire/ability to protect self and potential to recurrence of tissue damage Assess skin/tissues. change Identify underlying condition involves in tissue injury data Suggest treatment options.which leads to impaired tissue integrity. or as appropriate.
Help client and family to identify effective successful coping mechanisms and to implement them Discuss importance of early detection and reporting of changes in condition or any unusual physical discomforts Emphasize need to adequate nutritional/fluid intake Provide warm compress To reduce discomfort and improve quality of life Promotes early interventions/ reduces potential complications Optimize healing potential To improve circulation .
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