NURSING CARE PLAN Dengue Hemmorhagic Fever

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION/OUTCOME

 SUBJECTIVE
”Naghihiranat ini hiya balik-balik”
as verbalized by the patient’s SO.
 OBJECTIVE
Vital Signs taken as follows
Hyperthermia related to underlying
disease process
After 2 hours of nursing
intervention client will be able to
maintain core temperature within
normal range as evidened by: body
temperature is lowered to 37.5-
35.5 degree celcius.
Independent:
-Provide tepid sponge bath
-Promote surface cooling by means
of undressing
-Heat loss by means of evaporation
and conduction
-Heat loss by means of rdiation and
conduction
After 4 hours of nursing
intervention goals and objectives
have been met as evidenced by:
-Body temperature lowered to
37.5-36.5 degree celcius

T - 37.8 C -Provide cool environment -Heat loss by means of convection

P - 72bpm
R - 22cpm -To reduce metabolic demands of
BP - 100/70 -Maintain bed rest or minimize oxygen consumption
O2 - 96% movemement
-To prevent dehydration
-Discuss importance of adequate
fluid intake particularly to the
parents
-To know if the patient’s
-Strictly monitor temperature temperature went down to normal
value

-Increase fluid intake -To lower the temperature

Dependent:

Administer paracetamol as -To alleviate the fever of the

prescribed by the physician patient

Collaborative:

Refer to the physician if the -To monitor patients’s condition

temperature still higher than
normal range.
NURSING CARE PLAN Dengue Hemmorhagic Fever
ASSESSMENT NURSING DIAGNOSIS
 OBJECTIVE Anxiety Realated to Change in
Poor eye contact Health Status
Restlessness
Increased weariness DEFINITION
Facial flushing Vague uneasy feeling of
Decreased blood pressure discomfort or dread
accompanied by an autonomic
Vital Signs taken as follows response (the source often non-
specific or unknown to the
T – 37.8 C individual); a feeling of
P – 72bpm apprehension cause by
R – 22cpm anticipation of danger. It is an
BP – 100/70 altering signal that warns of
O2 – 96% impending danger and enables
the individual to take measures.
PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION/OUTCOME
At the end of my shift, the Independent:
patient will be able to:
-Monitor vital signs -To identify physical responses
1. Appear relaxed and associated with both medical 1. Goal met as evidenced
reort anxiety is reduced and emotional conditions by appearance of
to a manageable level. relaxation and report of
-Observe behavior -To which can point the client’s anxiety is reduced to a
2. Verbalize awareness of level of anxiety (mild, moderate, manageable level
feeling anxiety. severe, panic)
2. Goal met as evidenced
-Determine current prescribed -These medications can by verbalized
3. Identify healthy ways to medications and recent drug heighten feelings and sense of awareness of feelings of
deal with and express history of current prescribed or anxiety anxiety
anxiety. over-the-counter medications
3. Goal partially met as
4. Demonstrate problem -Review coping skills used in the -To determine those that might evidenced by identified
solving skills. past be helpful in current healthy ways to deal
circumstances with an expressed
anxiety
5. Use resources/support -Be aware of defense -To identify if there is
systems effectively. mechanism being used interference that deals with the 4. Goal partially met as
client’s ability evidenced by
demonstrated some
-Provide accurate information -Helps client to identify what is problem solving skills
about the situation based
5. Goal partially met. Used
resources/support
systems effectively.
NURSING CARE PLAN Dengue Hemmorhagic Fever
ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION/OUTCOME

 OBJECTIVE Impaired Comfort related to At the end of my five hour shift, Independent:
Restlessness underlying disease process the patient will be able to:
Sunken Eye -Determine locus of control -Presence of esternal locus of
Facial Flushing DEFINITION Engage in behaviors or lifestyle control may hamper efforts to Goal met as evidenced by engaged
Perceived lack of ease, relief changes to increase level of achieve sence of peace or in behavior or lifestyle changes to
and transcendence in physical, ease contentment increase level ofe ease
Vital Signs taken as follows
psychospiritual, environmental
-Determine the type of discomfort -Helps to determine clien’s specific Goal met as evidenced verbalized
T – 37.8 C and social dimensions Verbalize sense of comfort or
the client is experiencing such as needs, ability to changeown sense of comfort and contentment
P – 72bpm contentment situation
physical pain, feeling of discontent,
R – 22cpm
lack of ease in social settings or Goal met as evidenced by
BP – 100/70 Participate in desirable and inability to rise one’s problems or participation in desirable and
O2 – 96% realistic health-seeking pain realistic health-seeking behaviors
behaviors
-Discuss concerns with client and
actively listen to identify underlying
issues

-Determine how client is managing -Lack of control may be related to

pain and pain components issues, or emotions such as fear,
loneliness, anxiety, noxious,
stimuli, anger

-Review knowledge base and note -Brings these to client’s awareness

coping skills that had been used and promotes use in current
previously to change situation
behavior/promote well-being

-Establish realistic activity goals Enhances commitment promoting

with client optimal outcomes

-Review medications treatment To determine possible changes or

regimen options to reduce side effects

-Provide age appropriate comfort To provide non-pharmacologic pain

measures management
NURSING CARE PLAN Dengue Hemmorhagic Fever
ASSESSMENT NURSING DIAGNOSIS
 OBJECTIVE Risk for injury related to
Patient manifested the abnormal blood profile as
following which puts him at evidenced by decreased platelet
risk count
-Low platelet count
(100 x10^9 g/L) DEFINITION
Risk of Injury as a result of
Vital Signs taken as follows environmental conditions
interacting with the individuals
T – 37.8 C adaptive and defensive
P – 72bpm resources. It is also because of
R – 22cpm the infection of DHF I Virus that
BP – 100/70 destroys the platelets which
place the patient at risk of
bleeding. When the blood
vessels are cut or damaged, the
loss of blood from the system
must be stop before shock and
possible death may oocur. This
is accmpanied by solidification
of the blood, a process called
coagulation or clotting. If the
value shoul stop below normal,
(150,000-450,000 g/dL), there is
a danger of uncontrolled
bleeding because of the
essential role the platelets have
in blood clotting.
PLANNING
Short Term:
After 4 hours of Nursing
Interventions, patient will
demonstrate techniques
behavior, lifestyle changes to
risk factors and protect itself
Long Term:
After 1 day of Nursing
Interventions, the patient will
be free from injury
NURSING INTERVENTIONS
-Establish rapport
-Assess level of consciousness
and cognitive level
-Provide safe environment (pad,
side rails, prevent falls)
-Observe for each stool color,
consistency and amount
-Observe for hemmorhagic
manifestation, ecchymosis,
epistaxis, Petechiae, and
bleeding gums
-Encourage intake of foods with
high content of Vitamin C
-Assess patients condition and
monitor vital signs
-Provide comfort measures,
such as stretching bed linens
-Avoid SC, IM route of injection
as possible
RATIONALE EVALUATION/OUTCOME
-To gain patient’s trust Short Term:
After 4 hours of Nursing
-Assists in determining the pt’s Interventions, patient have
ability to protect self and demonstrated techniques
comply with required self behavior, lifestyle changes to
protective actions risk factors and protect itself
-Minimizes injury to occur Long Term:
After 1 day of Nursing
Interventions, the patient have
-Permits detection of bleeding been free from injury
in GI tract
-Indicate altered clotting
mechanism
-Promoteshealing and boost the
resistance of the body against
infection
-To obtain baseline data
-To promote relaxation and
alleviate
Minimizes tendency of trauma
and bleeding
NURSING CARE PLAN Dengue Hemmorhagic Fever
ASSESSMENT NURSING DIAGNOSIS
 OBJECTIVE Ineffective tissue perfusion
Patient manifested related to decrease hgb
Appears pale and weak concentration
Flushed
DEFINITION
Vital Signs taken as follows Due to the replication of
dengue virus in the body, there
T – 37.8 C could be stimulation of
P – 72bpm production of kinine causing
R – 22cpm incease vascular permeability
BP – 100/70 leading to capillary damage.
Thus will cause internal
bleeding. This was manifested
through flushed appearance
PLANNING
Short Term:
After 3 hours of Nursing
Interventions the patient will
demonstrate behaviors that will
improve the tissue perfusion
Long Term:
After 2-3 days of Nursing
Interventions, the patient will
demonstrate increase tissue
perfusion AEB normal hgb level
count
NURSING INTERVENTIONS
-Establish good working
condition with the patient and
SO
-Assess the patient’s condition
-Monitor vital signs
-Assess for possible causative
factors related to temporarily
impaired arterial blood flow
-Monitor quality of all pulse
-Maintain optimal cardiac
output
-Review laboratory valuesand
note costuamry baseline data
RATIONALE EVALUATION/OUTCOME
-To gain patient’s trust Short Term:
After 3 hours of Nursing
Interventions the patient have
demonstrated behaviors that
-To have baseline data will improve the tissue
perfusion
-Needed for ongoing
comparison Long Term:
After 2-3 days of Nursing
-Early detection of cause Interventions, the patient have
facilitates prompt, effective demonstrated increase tissue
treatment perfusion AEB normal hgb level
count
-Loss of peripheral pulses must
be reported or treated
immediately
-To increase cellular oxygen
supply
To evaluate the importance of
Nursing Interventions given and
provide comparison by current
findings
DRUG STUDY
DRUG NAME INDICATION MECHANISM OF ACTION CONTRAINDICATION SIDE EFFECTS/ NURSING
ADVERSE EFFECTS RESPONSIBILITIES

Generic Name: Relief of minor aches and pains Mechanism of
Paracetamol such as headache, backache, Action:Paracetamol exhibits
menstrual cramps, muscular analgesic and antipyretic
Brand Name: aches, minor arthritis pain, activity by inhibiting
Biogesic toothache and pain associated prostaglandin synthesis. It
with common cold and flu produces analgesia by elevating
Dosage/Direction for Use: the pain threshold and
Adults and Children >12 antipyresis through action on
years: 1-2 tabs every 4-6 hrs, or the hypothalamic heat-
as needed. Do not take >8 tabs regulating center.
in 24 hrs. In therapeutic doses,
paracetamol's analgesic and
antipyretic action is comparable
to that of aspirin. Paracetamol
does not adversely affect
platelet function and
hemostasis
Hypersensitivity to
paracetamol.
Repeated administration in
patients with anemia, cardiac,
pulmonary, renal and hepatic
damage
Paracetamol when taken within
therapeutic levels have low
incidence of side effects. Skin
rashes or minor gastrointestinal
disturbances have been
reported. Paracetamol very
rarely aggravates bronchospasm
in patients who are sensitive to
aspirin and other nonsteroidal
anti-inflammatory drugs.
Although paracetamol does not
normally produce
methemoglobinemia or
hemolysis even after
overdosage or in patients with
glucose-6-phosphate
dehydrogenase deficiency,
there have been isolated
reports of these complications
Do not exceed the
recommended dosage.
Reduce dosage with hepatic
impairment.
Avoid using multiple
preparations containing
acetaminophen. Carefully check
all OTC products.
Give drug with food if GI upset
occurs
Discontinue drug if
hypersensitivity occurs
Treatment for overdose:
Monitor serum levels regularly,
N-acetylcysteine should be
available as specific andecdote;
basic life support mesures may
be necessary.
DRUG STUDY
DRUG NAME INDICATION
Generic Name: Prophylaxis and treatment of
Ascorbic Acid scurvy and as a dietary
supplement. Increases
Brand Name: protection mechanism of the
Vita-C immune system, thus
supporting wound healing.
Necessary for wound healing
and resistance to infection.
MECHANISM OF ACTION
Water-soluble vitamine
essential for synthesis and
maintenance of collagen and
intercellular ground substance
of body tissue cells, blood
vessels, cartilage, bones, teeth,
skin and tendons. Unlike most
mammals, humans are unable
to synthesize ascorbic acid in
the body; therefore it must be
consumed daily.
CONTRAINDICATION
Use of sodium ascorbate in
patients on sodium restriction;
use of calcium ascorbate in
patients receiving digitalis.
Safety during pregnancy
(Category C) or lactation is not
established.
SIDE EFFECTS/
ADVERSE EFFECTS
GI: Nausea, vomiting,
heartburn, diarrhea, or
abdominal cramps (high doses).
Hematologic: Acute hemolytic
anemia (patients with
deficiency of G6PD); sickle cell
crisis.
CNS: Headache or insomnia
(high doses)
Urogenital: Urethritis, dysuria,
crystalluria, hyperoxaluria, or
hyperuricemia (high doses).
Other: Mild soreness at
injection site; dizziness and
temporary faintness with rapid
IV administration.
NURSING
RESPONSIBILITIES
High does of vitamin C are not
recommended during
pregnancy.
Take large doses of vitamin C in
divided amounts because the
body uses only what is needed
at a particular time and excretes
the rest in urine.
Megadoses can interfere with
absorption of vitamin B12
Note: Vitamin C increases the
absorption of iron when taken
at the same tine as iron-rich
foods.
Do not breasfeed while taking
this drug without consulting a
physician.
Submitted by: Chareigna R. Magallanes, SN
BSN 4 – GROUP 3

Submitted to: Mrs. Josephine P. Aguilos, RN

Clinical Instructor