EMILIO AGUINALDO COLLEGE

School of Nursing

NURSING CARE PLAN

CASE SCENARIO
Mahkulit is admitted 10 years old, female diagnosed with dengue hemorrhagic fever. IV PNSS 500ml run for 6 hours. Vital Signs: Temp: 39.2c; RR: 36; PR: 75;
“Masakit ang dyan ko”. Paracetamol 200mg PRN IV.

Name: Mahkulit Gender: F

Age: 10 Bed No. 258

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Hyperthermia related to After 4 hours of nursing INDEPENDENT: After 4 hours of nursing
Patient expressed “ process of dengue virus intervention patient will : - Strictly monitored - To know if the interventions goals and
Masaki ang dyan ko” infection as evidenced by patient’s temperature patients temperature objectives were met as
Temperature 39.2C and - Maintain core q1. went down to normal. evidenced by:
skin warm to touch. temperature within - Body temperature
OBJECTIVE: normal range. - Provided tepid - Heat loss by means lowered to 37C or
V\S sponge bath. of evaporation and normal range.
Temp: 39.2C conduction.
RR: 36
PR: 75 - Discussed the - To prevent
Skin warm to touch importance of dehydration.
adequate fluid intake
particularly to
parents.

- To treat or reduce
DEPENDENT: fever.
- Administered
Paracetamol 200mg, - Used as a
PRN through IV. nonpyrogenic
solution to replenish
- Administered PNSS fluids and
500ml run for 6 hours electrolytes.
through IV given at
10:35am.

COLLABORATIVE: - Sodium losses occur

- Reviewed serum, with profuse sweating
electrolytes, and accidental
 especially serum hyperthermia.
sodium referred to
Medical Technology
Department.
SOURCE: NANDA,2019