ACTUAL NURSING CARE PLAN Dengue Hemorrhagic Fever

CUES AND EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: Natatakotakos asakitko as verbalized by the patient. OBJECTIVE: Poor eye contact Restlessness Increased weariness Voice quivering Facial flushing Increased pulse rate Decreased blood pressure VS: T- 38 C P- 102 bpm R- 26 cpm
BP- 90/60 mmHg

Anxiety Related to Change in Health Status DEFINITION: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension cause by anticipation of danger. It is an altering signal that warns of impending danger and enables the individual to take measures.

At the end of my shift, the patient will be able to: 1. Appear relax and report anxiety is reduced to a manageable level. 2. Verbalize awareness of feeling of anxiety. 3. Identify healthy ways to deal with and express anxiety. 4. Demonstrate problem solving skills. 5. Use resources/ supportsystems effectively.

INDEPENDENT: Monitor vital signs To identify physical responses associated with both medical and emotional conditions To which can point the clients level of anxiety (mild, moderate, severe, panic) These medications can heighten feelings and sense of anxiety

1. Goal met as evidenced by appearance of relaxation and report of anxiety is reduced to a manageable level. 2. Goal met as evidenced by verbalized awareness of feelings of anxiety. 3. Goal partially met as evidenced by identified healthy ways to deal with an expressed anxiety. 4. Goal partially met as evidenced by demonstrated some problem solving skills.

Observe behavior

Determine current prescribed medications and recent drug history of current prescribed or over-the-counter medications Review coping skills used in the past Be aware of defense mechanism being used

To determine those that might be helpful in current circumstances To identify if there is interference that deals with the clients ability

REFERENCE: Nurses Pocket Guide 12th edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr

Provide accurate information about the situation Accept client as is

Helps client to identify what is based The client may need to be where she at this point in time, such as in denial after receiving the diagnosis of a terminal illness

5. Goal partially met. Used resources/sup port systems effectively.

ACTUAL NURSING CARE PLAN Dengue Hemorrhagic Fever

CUES AND EVIDENCES
SUBJECTIVE: Hindi akomakatulog ngmaayos as verbalized by the patient. OBJECTIVE: Restlessness Irritability VS: T- 39.2 C P- 97 bpm R- 23 cpm
BP- 90/60 mmHg

NURSING DIAGNOSIS
Impaired Comfort related to be developed DEFINITION: Perceived lack of ease, relief and transcendence in physical, psychospiritual, environmental and social dimensions. REFERENCE: Nurses Pocket Guide 12th edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr

OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION

At the end of my five hour shift, the patient will be able to: 1. Engage in behaviors or lifestyle changes to increase level of ease. 2. Verbalize sense of comfort or contentment. 3. Participate in desirable and realistic healthseeking behaviors.

INDEPENDENT: Determine locus of control Determine the type of discomfort client is experiencing such as physical pain, feeling of discontent, lack of ease in social settings or inability to rise ones problems or pain Discuss concerns with client and active listen to identify underlying issues Determine how client is managing pain and pain components Presence of external locus of control may hamper efforts to achieve sense of piece or contentment

1. Goal met as evidenced by engaged in behavior or lifestyle changes to increase level of ease. 2. Goal met as evidenced by verbalized sense of comfort or contentment. 3. Goal met as evidenced by participation in desirable and realistic healthseeking behaviors.

Helps to determine clients specific needs, ability to change own situation Lack of control may be related to issues, or emotions such as fear, loneliness, anxiety, noxious, stimuli, anger

Review knowledge base and note coping skills that had been used previously to change behavior/promote well-being Establish realistic activity goals with client Review medications or treatment regimen Provide age appropriate comfort measures

Brings these to clients awareness and promotes use in current situation Enhances commitment promoting optimal outcomes To determine possible changes or options to reduce side effects To provide nonpharmacologic pain management To promote physical stability

COLABORATIVE: Collaborate in treating or managing medical conditions involving oxygenation elimination, mobility, cognitive abilities, electrolyte balance, thermoregulation, hydration

ACTUAL NURSING CARE PLAN Dengue Hemorrhagic Fever

CUES AND EVIDENCES
SUBJECTIVE: Nilalagnatako as verbalized by the patient. OBJECTIVE: Increase body temperature above normal range. Flushed skin; warm to touch Tachycardia Seizures T- 40.2 C P- 113 bpm R- 40 cpm
BP- 90/50 mmHg

NURSING DIAGNOSIS
Hyperthermia related to illness DEFINITION: Body temperature elevated above normal range. REFERENCE: Nurses Pocket Guide 12th edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr

OBJECTIVES
At the end of my five hour shift, the patient will be able to: 1. maintain core temperature within normal range 2. Identify underlying cause or contributing factors and importance of treatment, as well as sign and symptoms requiring further evaluative or intervention. 3. Demonstrate behaviors to monitor and promote normothermia 4. Be free of seizures activity

INTERVENTIONS
INDEPENDENT: Assess underlying cause Monitor vital signs Monitor respirations

RATIONALE

EVALUATION
1. Goal met as evidenced by maintained core temperature within normal range. 2. Goal met as evidenced byidentified underlying cause or contributing factors and importance of treatment, as well as sign and symptoms requiring further evaluative or intervention. 3. Goal met as evidenced by demonstrated behaviors to monitor and promote normothermia .

Monitor and record all sources of fluid loss such as urine vomiting and diarrhea; wounds, fistulas; and insensible losses Maintain bed rest

Monitor ventilation may initially be present, but ventilatoryeffo rt may eventually be impaired by seizures, hyper metabolic state. To reduce metabolic demands and consumption

To support circulating volume and tissue perfusion

Administer replacement fluids and electrolytes Discuss importance of adequate fluid intake.

To prevent dehydration To control shivering

4. Goal met as evidenced by free of seizure activity.

DEPENDENT: Administer medications as ordered

ACTUAL NURSING CARE PLAN Dengue Hemorrhagic Fever

CUES AND EVIDENCES
SUBJECTIVE: Bumabalik at nawawalaangla gnatko as verbalized by the patient. OBJECTIVE: Fluctuate in body temperature above and below normal range Tachycardia Mild shivering Slow capillary refill VS: T- 39.2 C P- 97 bpm R- 23 cpm
BP- 90/60 mmHg

NURSING DIAGNOSIS
Ineffective thermoregulation related to illness DEFINITION: Temperature fluctuation between hypothermia and hyperthermia REFERENCE: Nurses Pocket Guide 12th edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr

OBJECTIVES
At the end of my five hour shift, the patient will be able to: 1. Verbalize understanding of individual factors and appropriate interventions 2. Demonstrate techniques and behavior to correct underlying condition or situation 3. Maintain body temperature within normal range

INTERVENTIONS
INDEPENDENT: Identify individual factors or underlying condition Initiate emergent or immediate interventions prepare client and assist with procedures

RATIONALE

EVALUATION
1. Goal met as evidenced by: Verbalized understanding of individual factors and appropriate interventions 2. Goal met as evidenced by: Demonstrated techniques and behavior to correct underlying condition or situation 3. Goal met as evidenced by: Maintained body temperature within normal range.

It influences choice of intervention To restore or maintain body temperature within normal range To treat underlying cause of hypothermia and hyperthermia To restore or maintain body and organ function

DEPENDENT: Administer fluids, electrolytes and medications, as appropriate

ACTUAL NURSING CARE PLAN Dengue Hemorrhagic Fever

CUES AND EVIDENCES
SUBJECTIVE: nanghihinaako as verbalized by the patient. OBJECTIVE: Poor skin turgor Decrease urine output Decrease blood pressure Elevated hematocrit VS: T- 39 C P- 100 bpm R- 30 cpm
BP- 90/50 mmHg

NURSING DIAGNOSIS
Deficient fluid volume related to failure of regulatory mechanism DEFINITION: Decreased intravascular, interstitial, and or intracellular fluid. This refers to dehydration, water loss alone without change in sodium. REFERENCE: Nurses Pocket Guide 12th edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr

OBJECTIVES
At the end of my five hour shift, the patient will be able to: 1. Maintain fluid volume at a functional level as evidenced individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill, resolution of edema 2. Verbalize understanding of causative factors and purpose of individual therapeutic interventions and medications 3. Demonstrate behaviors to monitor and correct deficit as indicated

INTERVENTIONS
INDEPENDENT: Assess vital signs, noting low BPsevere hypotension, rapid heartbeat, and thread peripheral pulses Establish 24hour fluid replacement needs and routs to be used Change position frequently Provide frequent oral and eye care Encourage increase OFI Recommend restriction of caffeine alcohol as indicated

RATIONALE

EVALUATION
1. Goal met, as evidenced by clients response to interventions, teaching, and actions, performed 2. Attainment or progress towards desired outcome 3. Modification to plan of care

These changes in vital signs are associated with fluid volume loss and or hypovolemia Prevents peaks and valleys in fluid level To reduce pressure on fragile skin and tissue To prevent from injury from dryness For fluid replacement To reduce effects of diuresis

DEPENDENT: Administer medications as ordered

For treatment regimen

POTENTIAL NURSING CARE PLAN Dengue Hemorrhagic Fever

CUES AND EVIDENCES
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred; rather, nursing interventions are directed at prevention

NURSING DIAGNOSIS
Risk for Bleeding related to inherent coagulopathies DEFINITION: At risk for a decrease in blood volume that may compromise health. REFERENCE: Nurses Pocket Guide 12th edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr

OBJECTIVES
At the end of my five hour shift, the patient will be able to: 1. Be free of signs of active bleeding 2. Display laboratory results for clotting times and factors within normal range for individual risks and engage in appropriate behaviors of lifestyle changes to prevent or reduce frequency of bleeding episodes

INTERVENTIONS
INDEPENDENT: Monitor vital signs Evaluate clients medication regimen

RATIONALE

EVALUATION
1. Goal met as evidenced by being free of signs of active bleeding. 2. Goal met as evidenced by satisfactory laboratory results for clotting times and factors within normal range and engaging in appropriate behaviors of lifestyle changes.

Maintain patency of vascular access

Necessity of regular medical and laboratory follow-up when on anticoagulants, such as Coumadin

Use of medications such as nonsteroidal antiinflammatory drugs etc. predispose client to bleeding For fluid administration or blood replacement as indicated To determine needed dosage change, or client management issues requiring monitoring and/or modification

Dietary measures

DEPENDENT: Administer medications as ordered

To promote blood clotting, when indicated, such as food rich in vitamin K

POTENTIAL NURSING CARE PLAN Dengue Hemorrhagic Fever

CUES AND EVIDENCES
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred; rather, nursing interventions are directed at prevention

NURSING DIAGNOSIS
Hypovolemia risk for shock DEFINITION: At risk for an inadequate blood flow to the bodys tissue which may lead to lifethreatening cellular dysfunction REFERENCE: Nurses Pocket Guide 12th edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr

OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION

At the end of my five hour shift, the patient will be able to: 1. Display hemodynamic stability as evidence by vital signs within normal range for client; prompt capillary refill; adequate urinary output within normal specific gravity; usual level of mentation. 2. Be afebrile and free of other signs of infection, achieve timely wound healing. 3. Verbalize understanding of disease process, risk factors, and treatment plan.

INDEPENDENT: Monitor vital signs Monitor intake/output Assess for history or presence of conditions leading to hypovolemic shock

DEPENDENT: Administer fluids, electrolytes, colloids, blood or blood products as indicated

Teach client purpose, dosage, schedule, precautions, and potential sideeffects of medications given to treat underlying conditions.

These conditions deplete the bodys circulating blood volume and ability to maintain organ perfusion and function To rapidly restore or sustain circulating volume, electrolyte balance, and prevent shock Enhances compliance with drug regimen, reducing individual risk

1. Goal partially met as evidenced by hemodynamic stability. 2. Goal partially met as evidenced by achieved timely wound healing but has an elevated body temperature. 3. Goal met as evidenced by verbalized understanding of disease process, risk factors, and treatment plan.

Encourage consumption of healthy diet, participation in regular exercise, adequate rest

For healing and immune system support

POTENTIAL NURSING CARE PLAN Dengue Hemorrhagic Fever

CUES AND EVIDENCES
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred; rather, nursing interventions are directed at prevention

NURSING DIAGNOSIS
Illness risk for powerlessness DEFINITION: At risk for perceived lack of control over a situation and/or ones ability to significantly affect an outcome REFERENCE: Nurses Pocket Guide 12th edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr

OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION

At the end of my five hour shift, the patient will be able to: 1. Express sense of control over the present situation and hopefulness about future outcomes. 2. Verbalize positive selfappraisal in current situation. 3. Make choices related to and be involved in care. 4. Identify areas over which individual has control. 5. Acknowledge reality that some areas are beyond individuals control.

INDEPENDENT: Assess clients self-esteem and degree of mastery client has exhibited in life situations Be alert for signs of manipulative behavior and note reactions of client and care givers Make time to listen to clients perception of the situation Encourage questions Provide accurate verbal and written instructions about what is happening and what realistically might happen.

Passive individual may have more difficulty being assertive and standing up for rights Manipulation may be used for management of powerlessness because of fear and distrust Shows concern for client as a person

1. Goal met as evidenced by expressed sense of control over the present situation and hopefulness about future outcomes. 2. Goal met as evidenced by verbalized positive selfappraisal in current situation. 3. Goal met as evidenced by choices made related to and be involved in care. 4. Goal met as evidenced by identified areas over which individual has control.

Reinforces learning and promotes selfplaced review

5. Goal met as evidenced by clients acknowledge ment of reality that some areas are beyond individuals control.