Assessment Diagnosis Planning Inference Implementation Rationale Evaluation

 Subjective Hyperthermia After 2 hours Body temperature Independent: After 4 hours of

“Ang init init ng related to of nursing elevated above - Provide tepid -Heat loss by nursing
kapatid ko inappropriate intervention normal level that is sponge bath means intervention
kapag clothing client will be usually caused by of evaporation goals and
hinahawakan” factor as able to several factors and conduction. objectives was
As verbalized evidenced maintain core related to illness. met as evidenced
by the patient’s by decrease temperature As inoculation -Promote surface -Heat loss by by:
sister. in platelet within normal occurs, proliferation cooling by means means
count secondary range as of virus follows and of undressing of radiation and -Body
to dengue evidenced by: once the virus starts conduction temperature
hemorrhagic - body to grow in number, lowered to 37
 Objective fever. temperature is it will soon reach - Provide cool -Heat loss by degree celcius.
- V/S taken as lowered to 37 it pathogenic level environment means
follows degree celcius. that will result of convection
into pyrexia or
T- 38 degree fever as a defense -Maintain bed - To reduce
celcius mechanism of the rest or minimize metabolic
PR- 88 bpm body. movement demands of
RR-22 cpm oxygen
BP-110/70 consumption
mmHg Reference: Nurse’s
pocket guide by - Discuss - To prevent
- Flushed skin Marilyn importance dehydration
- Warm to Doeges10th edition of adequate fluid
touch intake particularl
y to the parents.

- Strictly monitor - To know if the

temperature patient’s
temperature
went down to
the normal
 value.

-Increase fluid - To lower the

intake temparature

Dependent:
Administer - To alleviate
paracetamol as the fever of the
prescribed by the patient.
physician.

Collaborative:
Refer to the - To monitor
physician if the patient’s
temperature still condition.
higher to normal
range.
Assessment Diagnosis Planning Inference Implementation Rationale Evaluation
 Subjective Risk for -After 3 hours of nursing Most dengue -Assess the signs and -The GI tract is the -After 3 hours
“Dumudugo hemorrhage interventions, the client infections symptoms of most usual source of nursing
yung labi ng related to will be able to result in GI bleeding. of bleeding of its interventions, the
kapatid ko” altered clotting demonstrate behavior relatively -Check mucosal fragility client’s sister is able to
As factor. s that reduce the risk of mild illness, for secretions. demonstrate behavior
verbalized bleeding but some can -Observe color and s that reduce the risk
by the progress to consistency of stools of bleeding.
patient’s dengue or vomitus.
sister hemorrhagic
 Objective fever. With -Observe for -Sub-acute
-Weakness and dengue presence disseminate dintra-
irritability hemorrhagic of petichiae, vascular
-Restlessness fever, the ecchymosis, bleedin coagulation may
-V/S taken as blood vessels g from one more develop secondary
follows: start to leak sites. to altered clotting
T- 38.1 and cause factor.
PR- 90 bpm bleeding from
R- 22 cpm the nose, -An increase in
BP- 110/70 mouth, and pulse with decrease
mmHg gums. -Monitor pulse, BP BP can indicate
Bruising can loss of circulating
be a sign of blood volume
bleeding
inside the -Changes may
body. indicate cerebral
Without -Note changes in perfusion problems
prompt level .
treatment, the of consciousness.
blood vessels -Minimal trauma
can collapse, -Encourage use of can cause mucosal
causing shock soft toothbrush. bleeding
(dengue Avoid straining in
shock stool, and forceful
syndrome). nose blowing. -Minimize damage
-Use small needles to tissues, reduce
for injections. risk for bleeding
Apply pressure to and hematoma.
veni puncture sites
for longer than usual.

Dependent: - To prevent
Don’t administer spontaneous
aspirin. bleeding.

Collaborative:
Check for platelet
count.
-To know the
Check for patency of the
hematocrit. hematocrit.

Report to
physician if
there’s a
continuous
bleeding.
Assessment Diagnosis Planning Inference Implementation Rationale Evaluation
Subjective: Acute pain and Long term: Pain Independent To rule out After 2 hours
“Sinasabi ng kapatid ko discomfort After 2 hours modulation 1. Assess worsening of of nursing
masakit daw tapos related to dengue of nursing refers to the client’s underlying interventions, the
tinuturo niya yung tyan hemorrhagic interventions, function of response to condition/ client was able to:
niya” As verbalized fever. As the client will neural cells to pain: development a. Report that her
by the patient’s evidence by be able to: inhibit, reduce, of pain was
sister. VAS of 5 out of or dampen the complications relieved from a
10. a. Verbalize intrinsic pain scale of 5 to
Objective: reports that modulatory Pain is 1 out of 10.
Facial grimace provide relief. activity of the -Perform pain subjective and b. Demonstrate
Clenching of fists b. Demonstrate central nervous assessment cannot be felt duse of
Pain scale of 5 out use of system, thus each time pain by others relaxation skills
of 10. relaxation reducing the occurs. and diversional
Vital Signs: skills and painful stimuli. Observations activities.
BP-110/70 diversional Perception is -Accept client’s may not be
PR-88 activities as the conscious description of congruent with
RR-22 indicated for awareness, pain verbal reports.
T-37.6 individual usually -Observe
VAS-5 out of 10 situation. localized in nonverbal cues
certain areas of Usually
Short term: the body. -Monitor vital altered in
After 30 Level of pain signs acute pain
minutes of perception
nursing depends on
intervention the factors such as 2. Assist client
patient can: personal to explore
a. Report pain is experiences, methods for
relieved/ immediate alleviation/cont
controlled environment, rol of pain:
from a pain and socio- -Work with
scale of 5 to 1 cultural client to
out of 10. influences. prevent pain.
-Provide quiet
environment,
calm activities

-Provide
comfort
measures like
change of
positions.

Dependent:
Administer
pain medicines
–Nuprin as
prescribed by
the physician.

Collaborative:
Check results
of the platelets
of the patient if
it’s already
higher than the
previous
laboratory.