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Cebu Normal University

College of Nursing
Cebu City

Mission-Vision: Care using Knowledge and Compassion


NURSING CARE PLAN

Client’s Name: J. C. C._____________________________________ Patient Care Classification:


Age: 12 y. o. Sex: M Civil Status: Single Religion: Roman Catholic _____Wholly Compensatory: Pts. Therapeutic self-care is accomplished by
Allergies: Food: None___________________________________ nurse
Drug: None___________________________________ __/__Partially Compensatory: Pt. performs some self-care measures
Diet: DAT_______________________________________________ _____Supportive Educative: Pt. accomplishes self-care measures
Date of Admission: January 18, 2011 ; 5:30 PM_________________ Clinical Division and Bed No: Pediatric Ward_________________________
Diagnosis: Dengue Hemorrhagic Fever Stage 1 Grade 1__________ Name of Physician: Dr. Francis Jalalon_____________________________

EXPECTED OUTCOME
DEFINING CHARACTERISITICS INTERVENTION AND RATIONALE
CRITERIA
Nursing Diagnosis: Short term: Independent
Fluid Volume deficit related to intravascular to Within 8 hours of nursing
interstitial plasma leakage and bleeding secondary interventions, patient will be
1. Monitor patient for serious bleeding, such as headache with
to disease process able to demonstrate
change in responsiveness, blurred vision, hematemesis,
interventions to monitor andhypotension, tachycardia, dizziness
S: > “Gisunggo man ko te,” as verbalized correct fluid volume deficit R = To prevent occurrence of shock
O: > received lying supine on bed, awake S = Doenges, et al. 2006, page 924
> with with IVF #4 D5NSS 1L @ 25gtts/min infusing Long term: 2. Weigh patient daily, monitor intake and output
well @ right arm with 950cc remaining level Within 3 days of nursing R = To determine degree of fluid deficit
> dry mucous membrane noted interventions, patient will S = Doenges, et al. 2004, page 257
> epistaxis noted maintain fluid volume at
> passage of watery, loose stool 3 times per day functional level. 3. Monitor patient’s vital signs
noted R = In order to assess patient’s response and progress in
> irritability observed the fluid
replacement therapy
S = Doenges, et al. 2004, page 257
3.Encourage patient to increase oral fluid intake
R = To prevent valleys in fluid level
S = Doenges, et al. 2004, page 257
4. Advise patient to maintain bed rest especially during
bleeding episodes.
R = To prevent further injury
S = Doenges, et al. 2004, page 257

5. Instruct patient to turn to sides frequently


R = Tissues are susceptible to breakdown because of
Laboratory: increased cellular fragility
Result Reference S = Doenges, et al. 2006, page 924
Platelet 100 109/L 150-400 109/L 6. Monitor/record all sources of fluid loss such as urine,
vomiting and diarrhea
CBC findings show that patient has R = Oliguria and or renal failure may occur due to
thrombocytopenia which indicates altered hypotension, dehydration and shock. These may
hemostasis due to direct destructive actions of the potentiate fluid and electrolyte losses
virus on bone marrow precursor cells and the liver. S = Doenges, et al. page 288
This causes bleeding leading to decreased blood 7. Provide safety precautions as indicated padded side rails,
volume in the body bed in low position
Theoretical Basis: R = To prevent client injury
Deficient fluid volume is defined as the S = Doenges, et al. 2006, page 924
decrease in intravascular, interstitial and or 8. Provide skin and mouth care
intracellular fluid (Doenges, et al. Page 255). R = Skin and mucous membranes are dry due to
Diminished liver function caused by the dehydration
presence of the virus leads to a decrease in S = Doenges, et al. 2006, page 924
synthesis of proteins. If plasma proteins are 9. Anticipate needs
depleted in the blood, the inward forces of colloid R=To reduce frustration and irritabiliy
osmotic pressure are decreased, allowing the S= Gulanick.1994, page 220
filtration effect to favor movement into the tissues
(Cuevas, 2007). Infection of target cells, primarily Collaborative
those of the reticuloendothelial system, by the virus 1. Monitor platelet count daily
causes direct damage to blood vessels which may R = To evaluate patient’s response to treatment
lead to increased permeability of the endothelial S = Doenges, et al. 2006, page 924
junctions. Both of these conditions cause plasma 2. Administer IV solutions as indicated like D5NSS
leakage in dengue hemorrhagic fever and may R = To provide prompt circulatory improvement
manifest as hemoconcentration (Bullock, 2000). S = Doenges, et al. 2006, page 924
Meanwhile thrombocytopenia which is caused
by decreased production of clotting factors in the Sources:
liver, causes bleeding leading to decreased blood Bullock, Barbara and R. Henze.2000. Focus on
volume in the body (Cuevas, 2007). Pathophysiology. Philadelphia: Lippincott Williams and
Wilkins
 Cuevas, et al. 2007. Public Health Nursing in the
Philippines. 10th Edition. Philippines
 Doenges, Marilynn, et. Al. 2006. Nursing
CarePlans. 6th Edition. Thailand: FA Davis
Company
Doenges, Marilynn, et. Al. 2004. Nurses’ Pocket Guide.
10th Edition. Thailand: FA Davis Company
Gulanick, et al.1994.Nursing Care Plans. 3rd
ed.Mosby:Missouri
Cebu Normal University
College of Nursing
Cebu City

Mission-Vision: Care using Knowledge and Compassion


NURSING CARE PLAN

Client’s Name: J. C. C._____________________________________ Patient Care Classification:


Age: 12 y. o. Sex: M Civil Status: Single Religion: Roman Catholic _____Wholly Compensatory: Pts. Therapeutic self-care is accomplished by
Allergies: Food: None___________________________________ nurse
Drug: None___________________________________ __/__Partially Compensatory: Pt. performs some self-care measures
Diet: DAT_______________________________________________ _____Supportive Educative: Pt. accomplishes self-care measures
Date of Admission: January 18, 2011 ; 5:30 PM_________________ Clinical Division and Bed No: Pediatric Ward_________________________
Diagnosis: Dengue Hemorrhagic Fever Stage 1 Grade 1__________ Name of Physician: Dr. Francis Jalalon_____________________________

DEFINING CHARACTERISITICS EXPECTED OUTCOME CRITERIA INTERVENTION AND RATIONALE

Nursing Diagnosis: Short term: Independent


Within 8 hours of nursing 1. Assess skin, noted color, skin turgor,
Impaired skin integrity related to mechanical factors
interventions, patient will and sensation. Describe and measure wounds
as evidenced by disruption of skin surface
demonstrate behavior in and observed changes. Monitor vital signs.
S: > “nangatol ako samad lawas” as verbalized by the preventing skin impairment. R= Establishes comparative baseline providing
patient opportunity for timely intervention.
S= Doenges, et al., 2006
O: > petechial rashes noted Long term: 2. Provide skin hygiene through sponge bathing &
> Presence of wounds in the lower right extremity and Within 3 days of nursing changing regularly
both forearms observed interventions, R= To maintain skin integrity at optimal
> pruritus noted The patient will be able to display level.
improvement of wound healing and S= Doenges, et al., 2004
will be able to understand and apply 3. Keep bed clothes dry, use non- irritating materials,
treatment/ or therapy, regimen to the & keep bed wrinkled free
skin impairment. R= To avoid lesions, scratching of skin &
harboring of microorganism.
S= Gulanick et al., 1994
4. Palpate skin lesions for size, shape, consistency,
texture & hydration
R= To assess extent of involvement of
skin impairment.
S= Gulanick et al., 1994
Laboratory:
5. Encourage reposition schedule for client
No significant laboratory findings R= To prevent friction that may cause
irritation of the skin.
S= Gulanick et al., 1994
Theoretical Basis:
6. Provide information to the client about
In dengue hemorrhagc fever, minimal bleeding is the importance of regular observation & effective
evident through petechial rashes and epistaxis. This skin care.
is due to the diminished liver function causing a R= To promote wellness by gaining
decrease in clotting factors production.
knowledge on treatment/ therapy.
Wounds are caused by alteration of the epidermis S= Gulanick et al., 1994
because of external factors such as shearing force. 7. Emphasize importance of adequate nutrition and
(Bullock, 2000) fluid intake.
R= Improved nutrition and hydration will improve
skin condition.
Sources: S= Doenges, et al., 2006
Bullock, Barbara and R. Henze.2000. Focus 8. Demonstrate to the family members on how to
on Pathophysiology. Philadelphia: Lippincott
Williams and Wilkins make a guava decoction to apply to the wound as
Doenges, Marilynn, et. Al. 2006. Nursing alternative disinfectant.
CarePlans. 6th Edition. Thailand: FA Davis R= Providing the family with alternative solution
Company
assists them in optimal healing with less expensive
Doenges, Marilynn, et. Al. 2004 Nurses’
Pocket Guide. 10th Edition. Thailand: FA resources.
Davis Company S= Doenges, et al., 2006
Gulanick, et al.1994.Nursing Care Plans. 3rd 9. Instructed family to clip and file nails regularly.
ed.Mosby:Missouri
R= Long and rough nails increase risk of skin
World Health Organization. 2009. Dengue
Hemorrhagic Fever. damage.
http://who.int [accessed October 10, 2009] S= Doenges, et al., 2004
10. Provided and applied wound dressings carefully.
R= Wound dressings protect the wound and the
surrounding tissues.
S= Doenges, et al., 2004
Cebu Normal University
College of Nursing
Cebu City

Mission-Vision: Care using Knowledge and Compassion


NURSING CARE PLAN

Client’s Name: J. C. C._____________________________________ Patient Care Classification:


Age: 12 y. o. Sex: M Civil Status: Single Religion: Roman Catholic _____Wholly Compensatory: Pts. Therapeutic self-care is accomplished by
Allergies: Food: None___________________________________ nurse
Drug: None___________________________________ __/__Partially Compensatory: Pt. performs some self-care measures
Diet: DAT_______________________________________________ _____Supportive Educative: Pt. accomplishes self-care measures
Date of Admission: January 18, 2011 ; 5:30 PM_________________ Clinical Division and Bed No: Pediatric Ward_________________________
Diagnosis: Dengue Hemorrhagic Fever Stage 1 Grade 1__________ Name of Physician: Dr. Francis Jalalon_____________________________

DEFINING CHARACTERISITICS EXPECTED OUTCOME CRITERIA INTERVENTION AND RATIONALE

Nursing Diagnosis: Short term: Independent


Acute pain related to liver enlargement and Within 8 hours of nursing interventions,
tenderness secondary to disease process patient will demonstrate appropriate 1.Perform routine comprehensive pain assessment,
interventions to relieve pain and including location, characteristic, onset, quality and
S: > “Sakit lagi akong tiyan,” as verbalized manifest decreased irritability. severity
O: > received lying supine on bed, awake R = In order to clarify cues of verbalizations of
> with with IVF #3 D5NSS 1L @ 25gtts/min infusing Long term: the patient
well @ right arm with 540 cc remaining level Within 3 days of nursing interventions, S = Doenges, et al. 2006, page 906
> tenderness at the right costal margin noted patient will report that pain is relieved 2. Monitor respirations, heart rate and blood
> grimaced face observed and controlled. pressure
> guarded behavior on epigastric area noted R = Changes in autonomic responses may
> with HR= 100 bpm indicate increased pain before child verbalizes.
> with pain score of 5 out of 10 S = Doenges, et al. 2006, page 906
> diaphoresis observed 3. Accept patient’s description of pain
> irritability noted R = Pain is a subjective experience
S = Doenges, et al. 2004, page 389
4. Provide comfort measures like repositioning and
back rub
R = To provide nonpharmalogical pain
management
S = Doenges, et al. 2004, page 390
5. Encourage to have diversional activities like
reading and talking to the significant others
R = In order to help distract child’s attention from
pain and reduce tension.
S = Doenges, et al. 2006, page 907
6. Encourage to have rest periods
Laboratory: R = It helps reduce fatigue and enhances coping
ability
No significant laboratory results S = Doenges, et al. 2006, page 907
7. Encourage use of relaxation techniques like focused
breathing
R = For nonpharmalogical pain management
Theoretical Basis: S = Doenges, et al. 2004,page 390
Pain is defined as an unpleasant sensory and 8. Provide calm and quiet environment
emotional experience associated with actual or R = To reduce patient’s irritability
potential tissue damage (Bullock, 2000). S = Doenges, et al. 2004, page 390
Enlargement of the liver (hepatomegaly) is 9. Anticipate needs
observed at some stage of dengue hemorrhagic R=To reduce frustration
fever as it compensates for its diminished function S= Gulanick.1994, page 220
secondary to direct destruction of the virus.
Epigastric discomfort, tenderness at the right Collaborative
costal margin, and generalized abdominal pain are
usually the complains of the patient. 1. Encourage parents to be present during
The liver is usually palpable early in the febrile procedures
phase, varying from just palpable to 2-4 cm below R = To comfort child
the right costal margin. Liver size is not correlated S = Doenges, et al. 2004, page 390
with disease severity (WHO, 2009) 2. Administer analgesics as indicated
R = To maintain acceptable level of pain
S = Doenges, et al. 2004, page 391
Sources: 3. Provide for individualized exercise program that
Bullock, Barbara and R. Henze.2000. Focus can be continued by patient when discharges
on Pathophysiology. Philadelphia: Lippincott R = To promote active, not passive role
Williams and Wilkins S = Doenges, et al. 2004, page 391
Doenges, Marilynn, et. Al. 2006. Nursing
CarePlans. 6th Edition. Thailand: FA Davis
Company
Doenges, Marilynn, et. Al. 2004 Nurses’
Pocket Guide. 10th Edition. Thailand: FA
Davis Company
Gulanick, et al.1994.Nursing Care Plans. 3rd
ed.Mosby:Missouri
World Health Organization. 2009. Dengue
Hemorrhagic Fever.
http://who.int [accessed October 10, 2009]
Cebu Normal University
College of Nursing
Cebu City

Mission-Vision: Care using Knowledge and Compassion


NURSING CARE PLAN

Client’s Name: J. C. C._____________________________________ Patient Care Classification:


Age: 12 y. o. Sex: M Civil Status: Single Religion: Roman Catholic _____Wholly Compensatory: Pts. Therapeutic self-care is accomplished by
Allergies: Food: None___________________________________ nurse
Drug: None___________________________________ __/__Partially Compensatory: Pt. performs some self-care measures
Diet: DAT_______________________________________________ _____Supportive Educative: Pt. accomplishes self-care measures
Date of Admission: January 18, 2011 ; 5:30 PM_________________ Clinical Division and Bed No: Pediatric Ward_________________________
Diagnosis: Dengue Hemorrhagic Fever Stage 1 Grade 1__________ Name of Physician: Dr. Francis Jalalon_____________________________

DEFINING CHARACTERISITICS EXPECTED OUTCOME CRITERIA INTERVENTION AND RATIONALE

Nursing Diagnosis: Short term: Independent


High Risk for Injury: hemorrhage related to Within 8 hours of nursing interventions, 1. Assess for signs and symptoms of G.I.
altered coagulation secondary to low platelet patient will demonstrate appropriate bleeding. Check for secretions. Observe color
count interventions to reduce the risk for and consistency of stools or vomitus.
bleeding. R= the GI tract is the most usual source of
S: > “Nagdugo man akong ilong te, kuyawan jud ko bleeding because of its mucosal fragility.
ky kaduha man to,” as verbalized by patient Long term: S= Bullock, 2000
Within 3 days of nursing interventions, 2. Observe for presence of petechiae,
O: > received lying supine on bed, awake there will be no occurrence of bleeding ecchymosis, bleeding from one more sites.
> with with IVF #3 D5NSS 1L @ 25gtts/min infusing episodes. R= Sub-acute disseminated intravascular
well @ right arm with 540 cc remaining level coagulation (DIC) may develop secondary to
> weakness and irritability noted altered clotting factors.
> restlessness observed S= World Health Organization, 2009
> history of epistaxis upon admission noted 3. Monitor pulse and blood pressure.
> Platelet count of 163x109/L R= An increase in pulse with decreased blood
pressure can indicate loss of circulating blood
volume.
S= Bullock, 2000
4. Note changes in mentation and level of
consciousness
R= Changes may indicate cerebral perfusion
secondary to hypovolemia and hypoxemia.
S= Doenges, Marilynn, et. Al., 2006
5. Avoid rectal temperature; be gently with GI tube
insertions.
R= Rectal and esophageal vessels are most
vulnerable to rupture.
Laboratory: S= Doenges, Marilynn, et. Al., 2006
6. Encourage use of soft toothbrush, avoiding
Platelet count of 163x109/L straining for stool, and forceful nose blowing.
R= In the presence of clotting factor
disturbances, minimal trauma can cause
mucosal bleeding.
Theoretical Basis: S= Doenges, Marilynn, et. Al., 2004
7. Use small needles for injections. Apply
Dengue fever infectious disease is manifested by a pressure to venipuncture sites for longer than
sudden onset of fever, with severe headache, usual.
muscle and joint pains, there may also be gastritis. R= Minimizes damage to tissues, reducing risk
Its fatal type is dengue hemorrhagic fever, this for bleeding and hematoma.
involves internal bleeding due to a drop in clotting S= Doenges, Marilynn, et. Al., 2004
factors caused by decreased liver function. (World 8. Recommend avoidance of aspirin containing
Health Organization, 2009) products.
R= Prolong coagulation, potentiating risk of
hemorrhage.
S= Doenges, Marilynn, et. Al., 2004
Sources:
Bullock, Barbara and R. Henze.2000. Focus
on Pathophysiology. Philadelphia: Lippincott Collaborative
Williams and Wilkins
Doenges, Marilynn, et. Al. 2006. Nursing 1. Monitor Hgb, Hct, Plt and clotting factors.
CarePlans. 6th Edition. Thailand: FA Davis R= these are indicators of anemia, active
Company bleeding, or impending complications.
S= Gulanick, et al,1994
Doenges, Marilynn, et. Al. 2004 Nurses’
Pocket Guide. 10th Edition. Thailand: FA
Davis Company
Gulanick, et al.1994.Nursing Care Plans. 3rd
ed.Mosby:Missouri
World Health Organization. 2009. Dengue
Hemorrhagic Fever.
http://who.int [accessed October 10, 2009]

Cebu Normal University


College of Nursing
Cebu City
Mission-Vision: Care using Knowledge and Compassion
NURSING CARE PLAN
Client’s Name: J. C. C._____________________________________ Patient Care Classification:
Age: 12 y. o. Sex: M Civil Status: Single Religion: Roman Catholic _____Wholly Compensatory: Pts. Therapeutic self-care is accomplished by
Allergies: Food: None___________________________________ nurse
Drug: None___________________________________ __/__Partially Compensatory: Pt. performs some self-care measures
Diet: DAT_______________________________________________ _____Supportive Educative: Pt. accomplishes self-care measures
Date of Admission: January 18, 2011 ; 5:30 PM_________________ Clinical Division and Bed No: Pediatric Ward__________________________
Diagnosis: Dengue Hemorrhagic Fever Stage 1 Grade 1__________ Name of Physician: Dr. Francis Jalalon_____________________________
DEFINING CHARACTERISITICS EXPECTED OUTCOME INTERVENTION AND RATIONALE
CRITERIA
Nursing Diagnosis: Short term: Independent
Hyperthermia related to dehydration and increased Within 8 hours of nursing 1.Monitor patient temperature (degree and pattern); note
metabolic rate secondary to disease process interventions,patient’s shaking chills and profuse diaphoresis.
temperature will decrease R = Fever pattern may aid diagnosis. Temperature of
S: > “Init kaayu ko te,” as verbalized from 38.5°C to 37.5°C 38.9°C-41.1°C suggests acute infectious process.
O: > received lying supine on bed, awake S = Doenges, et al. 2006, page 677
> with with IVF #2 D5NSS 1L @ 32gtts/min infusing well Long term: 2. Identify underlying cause.
@ right arm with 960 cc remaining level Within 3 days of nursing R = To assess causative factor and to know what
>Increased temperature noted= 38.5°C interventions, patient will appropriate interventions to provide
>Tachypnea noted= 25cpm maintain temperature within S = Doenges, et al. 2004, page 300.
>Flushed skin observed normal range and be free 3. Monitor heart rate and rhythm.
>Warm to touch of complications R = Dysrhythmia and ECG changes are common due to
dehydration, hyperthermia, etc.
S = Doenges, et al. 2004, page 300
4. Monitor respirations.
R = Hyperventilation may be present.
S = Doenges, et al. 2004, page 300
Laboratory: 5. Monitor/record all sources of fluid loss such as urine,
Result Reference vomiting and diarrhea, wounds and insensible losses.
Leukocyte 2.5 109/L 4.5 -13 109/L R = oliguria and or renal failure may occur due to
hypotension, dehydration and shock. These may
CBC findings show that patient has leukopenia which is potentiate fluid and electrolyte losses
frequently observed near the end of the febrile phase of S = Doenges, et al. 2004, page 301
illness. 6. Note presence/absence of sweating as body attempts to
increase heat loss by evaporation, conduction and diffusion.
Theoretical Basis: R = Evaporation is decreased by environmental factors of
Hyperthermia is defined by NANDA as the body high humidity and high ambient temperature as well as
temperature elevated above normal. (Doenges, et al. body factors producing loss of ability to sweat
Page 287) S = Doenges, et al. 2004, page 301
Dengue hemorrhagic fever commonly begins with a 7. Promote surface cooling by means of undressing and cool
sudden rise in temperature which is accompanied by environment and/or fans.
facial flush and other non-specific constitutional R = Heat loss by radiation, conduction and convection.
symptoms. After inoculation into a human host, viral S = Doenges, et al. 2004, page 301
replication takes place in target dendritic cells. Infection 8. Monitor environmental temperature; limit/add bed linens as
of target cells, primarily those of the reticuloendothelial indicated.
system, such as dendritic cells, hepatocytes, and R = Room temperature/number of blankets should be
endothelial cells, result in the production of immune altered to maintain near-normal body temperature.
mediators. Activation of the complement system is also S = Doenges, et al. 2006, page 677
a constant finding in patients with DHF. Levels of C3 9. Provide tepid sponge baths; avoid use of alcohol.
and C5 are depressed, and C3a and C5a are elevated. R = May help reduce fever. Alcohol may cause chills.
The complement system sets the stage for S = Doenges, et al. 2006, page 677
phagocytosis by neutrophils or macrophage. This leads 10. Maintain bedrest.
to the release of endogenous pyrogens from R = To reduce metabolic demands and oxygen
macrophages which act on the regulating centers in the consumption.
hypothalamus thus elevating thermostat set-point. S = Doenges, et al. 2004, page 301
(Bullock, 2000). 11. Discuss importance of adequate fluid intake.
Bleeding and plasma leakage occur as well in R = To prevent dehydration.
dengue hemorrhagic fever. Both predispose a decrease S = Doenges, et al. 2004, page 301
in blood volume which also contribute to alteration of 12. Anticipate needs
body’s thermoregulation and eventually cause fever R=To reduce frustration
(Cuevas, 2007). S= Gulanick.1994, page 220

Sources: Collaborative
Bullock, Barbara and R. Henze.2000. Focus on 1.Administer antipyretics (paracetamol) as ordered.
Pathophysiology. Philadelphia: Lippincott R = Used to reduce fever by its central action on the
Williams and Wilkins hypothalamus.
Cuevas, et al. 2007. Public Health Nursing in the S = Doenges, at al. 2006, page 677
Philippines. 10th Edition. Philippines 2. Administer replacement fluids and electrolytes.
Doenges, Marilynn, et. Al. 2006. Nursing R = To support circulating volume and tissue perfusion
CarePlans. 6th Edition. Thailand: FA Davis S = Doenges, et al. 2006, page 289
Company 3. Provide supplemental oxygen.
Doenges, Marilynn, et. Al. 2004. Nurses’ Pocket R =To offset increased oxygen demans and consumption.
Guide. 10th Edition. Thailand: FA Davis S = Doenges, et al. 2004, page 302
Company 4. Provide high-calorie diet.
Gulanick, et al.1994.Nursing Care Plans. 3rd R = To meet increased metabolic demands.
ed.Mosby:Missouri S = Doenges, et al. 2004, page 302