Date/Tim

Assessment

Need

Nursing Diagnosis

Objective of Care

Nursing Intervention

Evaluation

Subjective:

P
H
Y
S
I
O
L
O
G
I
C
(Temperature
Maintenance
)

Altered Body
Temperature:
Hyperthermia r/t
disease process
secondary to
Dengue fever

Within 4 hours of
nursing
intervention Body
temperature from
37.9C will
decrease between
range of 36.8C37.3C

Independent:
1.) Monitor Vital signs
* to have baseline data
2.) Applied TSB
* Evaporation helps in
cooling down skin
temperature
3.) Encourage to wear
loose clothing
*to be more
comfortable and easy
to move
4.) Opened the room
windows
*for ventilation
Dependent:
1.) Paracetamol 1 tab
500mg PRN given by
NOD
*for relief of pain and
reduce fever
Collaborative:
1.) Refer to Staff if
there are any
unusualities noted.
*To provide further
and appropriate care.

Goal: MET

8-10-15
7-3
10:30am

"Init akong
paminaw sa
akong lawas" as
verbalized.
Objective"
Skin:
-Dry
-very warm to
touch
-flushed skin
V/S:
T- 37.9 C
PR- 87 bpm
RR- 22 cpm
BP- 90/70 mmHg
Labs:
Leukocytes 2.08

Dengue fever is a
mosquito-borne
viral disease.
When an infected
mosquito feeds on
a person, it injects
the dengue virus
into the
bloodstream
Replicates inside a
dendritic cell
called a
Langerhans cell.
Travels to the
lymph nodes and
alert the immune
system that a
pathogen is in the
body.
As the immune
system fights the

Within 4 hours of
nursing
intervention boy
temperature
decreases as
manifested by
37C.

dengue infection,
the person
experiences a
fever.

Hyperthermia

Altered Body
Temperature
Source:
1.)
Nursing Diagnosis
Reference Manual
9th Edition 2009
2.)
(http://www.nature
.com/scitable/topic
page/hostresponse-to-thedengue-virus22402106)
3.)
(http://www.who.i
nt/mediacentre/fac
tsheets/fs117/en/)

Date/Tim
e
8-11-12
7-3
9:00am

Assessment

Need

Nursing Diagnosis

Objective of Care

Nursing Intervention

Evaluation

Subjective:
Sakit ilihok
akung lawas katol
pagyud as
verbalized.

P
H
Y
S
I
O
L
O
G
I
C

Risk for impaired

skin integrity R/t
inadequate
circulation S/t
immobility

Within the shift

will be able to
verbalize
understanding of
treatment needs.

Independent:
1.Monitored vital sign
*baseline data
2.Encouraged skin
hygiene trough sponge
bath and change
clothes regularly
*to avoid lesions,
scratching of skin and
harboring of
microorganism.
3.Instructed to
frequent change of
position
*to prevent friction
that may cause
irritation of the skin.
4.Provide Information
the importance of
regular observation
effective skin care.
*to promote wellness
gaining knowledge on
treatment therapy.
5.Emphasize the
importance of
nutritional fluid
intake.
*to maintain general
good health skin
turgor.
6.Assisted on active

GOAL MET:

Objective:
-dry and redness
of the skin
-skin rashes
-body weakness

VS:
(StimulationBP:110/70 mmHg Activity)
TEMP: 37.5C
RR:20
PR:119
Capillary
Refill:<2sec

R:
Immobility

Pressure applied to
soft tissue

Complete or
partially
obstructed blood
flow to the tissue.

Shear or friction

Present ulcers

Within the shift:

Verbalized
understanding of
treatment needs.

ROM exercises.
*to maintain joint
mobility an muscle
strength.
Independent:
1.CITIRIZINE as
prescribe by the
physician.
*Anti-histamine
*Use to treat allergic
reaction an colds.
COLLABORATIVE:
1. Instructed
watcher to trim
the nails.
*to reduce risk of
dermal injury were
severe itching his
present.

Date/Tim
e
08-13-15
7-3

Assessment

Need

Subjective:
gamay ra ang
kaya nako na
makaon

Physiological Imbalance nutrition:

less than body
need

7:00am
Objective:
Food
consume:
3-5 tbsp. only

Dry lips
Dry skin

Nursing Diagnosis

Objective of Care

Within 8 hours of
nursing care
requirements related
increased appetite
to loss of appetite
(Nutrition/flu secondary to Fever
is observed as
ids)
evidence by:
R:
During fever the
body produces
chemicals called
cytokines, which
have a wide range o
effects and are
partly responsible
for the decrease
appetite
Decreased strength
and stamina
Decreased food
intake
Intake insufficient to
meet metabolic
needs
Imbalanced
nutrition: less than
body requirements
http://www.huttingtonpost.
com/2014/01/06/loseappetite-cold-flu-sick n
4525367.html

Food
consume:
8- 10 tbsp.
Absence
of dry lips
and skin

Nursing Intervention

Evaluation

Independent

Goal met,
increased
appetite is
observed as
evidence by:

1. Provide small
frequent
feeding
*to reduce fatigue
and improve
intake
2. Promote
adequate rest
*to reduce fatigue
and improve the
childs ability and
desire to eat
3.Encouraged to
increase OFI
*to avoid
dehydration
Dependent:
1. Provide
potential fluids
as ordered
*to ensure
adequate fluid and
electrolyte levels.

Food
consumed
10 tbsp.
Absence
of dry lips
and skin

Collaborative:
1. Instructed
watcher to
bring foods
preferred.
*To promote appetite
2. Refer family to
dietitian
*To individualize
childs diet within
prescribed restrictions
2. Refer to NOD
any
unusualities
*To provide further
care and appropriate
care