ASSESMENT

11 Year old male pedia patient with Dengue Hemorrhagic Fever rushed in the E.R

SUBJECTIVE :

Nahihilo po ako, Nauuhaw at nanlalata as verbalized by the client. [ Means, I AM DIZZY, THIRSY AND I FEEL SO WEAK" ]

OBJECTIVE :

+ Sunken, Dry eyes + Pale palpebral conjunctiva + Dry lips and mouth +Prolonged Capillary refill time [ 7 seconds ] + Poor skin turgor + Rapid, Thready Pulse

Heart rate 110 Bpm RR 21 Bpm BP 90/60 Temp 39.2 C

DIAGNOSIS Fluid Volume Deficit R/T Intravascular to Extravascular Plasma Leakage Secondary to Increase in Vascular Permeability.

OBJECTIVES

SHORT TERM: After an hour of spontaneous fluid replacement, Patient will gradually abate signs and symptoms of fluid volume deficiency as evidenced by increasing blood pressure, decreasing heart rate, improving capillary refill time preferably below 5s and an improving skin turgor.

{ LONG TERM : After 2 days of nursing intervention, Patient will maintain fluid volume at an amount optimum for normal functioning as evidenced by a normal urine output with normal specific gravity, stable vital signs, moist mucus membrane, good capillary refill time and resolution of third spacing.}

INTERVENTION 1. Anticipate fluid replacement by preparing peripheral route for IV transfusion.

2. Obtain doctors order for IV therapy As soon as possible to replace fluid volume loss IMMEDIATELY.

3. Encourage fluid intake by placing a glass of juice or water within the patients reach.

4. Monitor total fluid intake and output every 2 hours.

5. Watch trends in output for 3 days; include all routes of intake and output and note color and specific gravity of urine.

6. Monitor vital signs of clients with deficient fluid volume every hour. Observe for decreased pulse pressure first, then hypotension, tachycardia, decreased pulse volume, and increased or decreased body temperature

RATIONALE

1. IV transfusion is a dependent nursing function. Anticipate doctors order by providing route for IV fluid replacement to save time and decrease risk for complications.

2. IV is considered as MEDICATION. Before initiating IV Replacement therapy, make sure that there is a current standing or verbal order from the doctor.

3. placing a glass of water or juice at patients bedside is the best way to encourage fluid intake. DHF patient are always thirsty prior to the defervescence stage.

4. A urine output of .5 ml per kg/hr is insufficient for normal renal function and indicates onset of renal damage

5. Monitoring for trends for 2 to 3 days gives a more valid picture of the client's hydration status than monitoring for a shorter period. Dark-colored urine with increasing specific gravity reflects increased urine concentration.

6. To monitor and assess clients response and progress in the fluid replacement therapy.

EVALUATION

SHORT TERM : After an hour of intervention, Patients BP increased to 100/70, Tachycardia resolved as evidenced by a normal HR of 80bpm. CRT decreased from 7s down to 4s and there is a noticeable improvement in the clients skin turgor.

{LONG TERM : 2 Days after a series of nursing care, the patient manifested a normal urine output of 30ml per hour with a specific gravity of 1.011. Stable vital signs were monitored and recorded. CRT was recorded normal. Physical assessment revealed no sign of fluid deficit.}

Subjective: (none) Objective: Decreased WBC Decreased platelet Decreased HgB Decreased capillary refill time Dysrhythmias Altered LOC Fever Chills Diaphoresis

Ineffective tissue perfusion related to decreased HgB concentration in the blood secondary to DHF 1

Short Term: After 4 hours of NI, the pt will demonstrate behaviours to improve circulation. Long Term:

Establish Rapport Monitor Vital Signs Assess patients condition

To gain pts trust To obtain baseline data To assess contributing factors For comparison with current findings To identify alterations from normal To identify / determine adequate perfusion To determine presence of thrombus formation To determine risk of anemia To promote circulation To promote comfort & decrease tissue O2 demand To decrease cardiac workload To enhance

The pt shall have demonstrated behaviours to improve circulation The pt shall have demonstrated increased perfusion as appropriate

Note customary After 4 days of baseline data NI, the pt will demonstrate Determine increased presence of perfusion as dysrhythmias appropriate Perform blanch test Check for Homans sign Note presence of bleeding Elevate HOB Encourage quiet & restful atmosphere Instruct to avoid tiring activities Encourage light ambulation Encourage use of relaxation techniques

Administer medications

venous return To decrease tension and anxiety level To treat underlying cause