KEY ISSUE DESIRED OUTCOME
Date identified: March 02, 2017
Ineffective Airway Clearance
related to retained secretions
secondary to pneumonia as
evidenced by unproductive cough.
Scientific Basis: The inflammation
and increased secretions make it
difficult to make a patent airway,
which is caused by decreased ability
to expel the excessive mucus
produced that will lead to extensive
obstruction of the airway.
Source: Smeltzer, S., Bare, B.,
Hinkle, J. & Cheever, K. (2010).
Medical surgical nursing (12th ed.).
Philadelphia, PA: Lippincott Williams
& Wilkins.
Within 2 days of student nurse-
patient interaction the patient will be
able to:
- Demonstrate behaviors which will
improve clear airway such huffing
and doing breathing exercises.
- Maintain airway patency through
effective coughing and
expectoration of secretions.
- Demonstrate absence or
reduction of congestion with
breath sounding clear, noiseless
respirations, and improved
oxygen exchange
INTERVENTION ACTUAL OUTCOME
Independent: After 8 hours of student nurse-patient
1. Assessed the rate and depth of respirations and chest interaction:
movement.
R: To monitor the clients health state and to Day 1 (March 2, 2017)
investigate any further complications.
Respiration Rate = 21 cpm
2. Monitored for signs of respiratory failure such as Crackles heard over lung fields
cyanosis and severe tachypnea. Verbalized, Im having difficulty spitting
R: Tachypnea, shallow, respirations, and asymmetric out ate"
chest movement are frequently present because of
Day 2 (March 3, 2017)
discomfort of moving chest wall or fluid in lung.
Respiration rate = 28 cpm
3. Auscultated lung fields, noting areas of decreased or
Crackles still heard over lung fields
absent airflow and adventitious breath sounds such as
Use of accessory muscles not noted
crackles and wheezes.
Verbalized, I can spit it out na ate"
R: Decreased airflow occurs in areas consolidated with
fluid. Bronchial breath sounds can also occur in
consolidated areas. Crackles, rhonchi, and wheezes
are heard in inspiration and expiration in response to
fluid accumulation, thick secretions, airway spasms or
obstructions.
4. Elevated head of bed and change position frequently.
R: Keeping the head elevated lowers diaphragm,
promoting chest expansion, aeration of lung segments,
and mobilization and expectoration of secretions to
keep the airway clear.
5. Assisted client with frequent deep-breathing exercises.
Demonstrated and helped client, as needed: learn to
perform activity such as coughing while in upright
position.
 R: Deep breathing facilitates maximum expansion of
the lungs and smaller airways. Coughing is a natural
self-cleaning mechanism, assisting the cilia to maintain
patent airways. An upright position favors deeper, more
forceful cough effort.

6. Encouraged client to walk around.

R: This reduces risk or effects of atelectasis, enhancing
lung expansion and drainage of different lung
segments.

7. Demonstrated to client specific airway clearance

techniques such as huffing.
R: Airway clearance techniques will help in
expectorating the secretions.

8. Encouraged to get some rest.

R: This prevents or reduces fatigue.

Collaborative:

1. Administration of Salbutamol (Ventolin) 2.5mg/2.5ml per

nebulization every 4 hours.
R: It relaxes the smooth muscles of the bronchioles
allowing maximum passage of air

Date identified: March 02, 2017
Hyperthermia related to release of
pyrogens as a response to infection
secondary to pneumonia as
manifested by elevated body
temperature of 38.3C/axilla, skin
warm to touch.
Desired outcome:
Within 2 days nursing intervention,
patients temperature will reduce to
within normal range and vital signs
will be stable.
Independent: After 8 hours of student nurse-patient
interaction:
1. Identified underlying cause.
R: to assess contributing factors
Day 1 (March 2, 2017)
2. Monitored core temperature
R: to evaluate the degree of hyperthermia Patients temperature increased to
38.6 C/axilla and vital signs were
3. Monitored blood pressure

Scientific Basis: Fever is the most
common sign of a systemic
response. It is caused by
endogenous pyrogens released from
neutrophils and macrophages. These
substances reset the hypothalamic
thermostat, which controls body
temperature and produce fever.
Source: Smeltzer, S., Bare, B.,
Hinkle, J. & Cheever, K. (2010).
Medical surgical nursing (12th ed.).
Philadelphia, PA: Lippincott Williams
& Wilkins.
R: central hypertension or peripheral/postural stable
hypotension can occur.
Day 2 (March 3, 2017)
4. Monitored heart rate and rhythm
R: dysrhythmias are common due to electrolyte Patient temperature decreased from
imbalance, dehydration and direct effects of 38.3C/axilla to 38.0C/axilla and vital
hyperthermia on blood on cardiac tissue. signs were stable
5. Monitored respirations and auscultated breath sounds
R: hyperventilation, adventitious breath sounds may
initially be present.
6. Monitored and recorded all sources of fluid loss such as
urine, respiration and perspiration.
R: decrease fluid in the body is one of the main causes
of hyperthermia.
7. Performed tepid sponge bath until afebrile.
R: to reduce body temperature through conduction.
8. Loosened linens and removed unnecessary clothing.
R: unnecessary coverings may increase body
temperature.
9. Provided a well ventilated environment
R: to promote heat loss by convection.
Collaborative:
1. Administered Paracetamol 500mg PRN
R: to relieve fever through central action in the
hypothalamic heat regulating center of the brain.
2. Administered IVF of D5LR 1L at 25 gtts/min.
R: to replace fluids and electrolytes and prevent
dehydration.
Date identified: March 02, 2017
Ineffective Cerebral Tissue
Perfusion related to increased
oxygen consumption as neuronal
firing increases secondary to dengue
fever as manifested by alterations in
the LOC, temporary loss of sensation
on both lower limbs and observable
hesitations upon movement.
Scientific Basis:
Source: Smeltzer, S., Bare, B.,
Hinkle, J. & Cheever, K. (2010).
Medical surgical nursing (12th ed.).
Philadelphia, PA: Lippincott Williams
& Wilkins.
Within 2 days of student nurse-
patient interaction the patient will be
able to:
- Improve LOC and sensory
function.
- Maintain usual cognition and
motor function.
Independent: After 8 hours of student nurse-patient
1. Monitor and document neurological status frequently interaction:
and compare with baseline.
R: Assesses trends in LOC and potential for increased Day 1 (March 2, 2017)
ICP and is useful in determining location, extent, and
progression or resolution of CNS damage. Increased temperature of 37.6oC
while other vital signs are within
2. Monitor vital signs noting: Hypertension or hypotension; normal limits
compare blood pressure (BP) readings in both arms,
heart rate and rhythm; auscultate for murmurs, Client is lethargic with a Glasgow
respirations, noting patterns and rhythmperiods of coma scale grading of 11
apnea after hyperventilation, Cheyne-Stokes
respiration. No recurrence of generalized tonic
seizure was noted
R: Fluctuations in pressure may occur because of
cerebral pressure or injury in vasomotor area of the
brain. Hypertension or hypotension may have been a
Day 2 (March 3, 2017)
precipitating factor. Changes in respiratory rate,
especially bradycardia, can occur because of the brain Increased temperature of 38.3oC
damage. Irregularities of heart rhythm can suggest while other vital signs are within
location of cerebral insult or increased ICP and need normal limits
for further intervention, including possible respiratory
support. Client is awake and responsive with
a Glasgow coma scale of 15
3. Evaluate pupils, noting size, shape, equality, and light
reactivity No recurrence of generalized tonic
R: Pupil reactions are regulated by the oculomotor (III) seizure was noted
cranial nerve and are useful in determining whether the
brainstem is intact. Pupil size and equality is
determined by balance between parasympathetic and
sympathetic enervation. Response to light reflects
combined function of the optic (II) and oculomotor (III)

Date Identified: March 2, 2017
Risk for bleeding related to
production of antibodies in
response to dengue virus
secondary to dengue fever
Cues:
- Positive NS1 test
- Decreased platelet count of
126 10e3/L (no= 440-140
10e3/L)
Desired Outcome:
Within 2 days of student nurse
and patient interaction, the patient
will be free from bleeding injury
cranial nerves.
4. Elevated head of bed and change position frequently.
R: Continual stimulation can increase ICP. Absolute
rest and quiet may be needed to prevent recurrence of
seizures.
5. Assess higher functions, including speech, if client is
alert.
R: Changes in cognition and speech content are an
indicator of location and degree of cerebral
involvement and may indicate increased ICP.
Collaborative:
1. Administration of Phenobarbital sodium 130 mg/ml
IVTT q 8H
R: Phenobarbital acts on GABA receptors, increasing
synaptic inhibition. This has the effect of elevating
seizure threshold and reducing the spread of seizure
activity from a seizure focus.
1. Assessed vital signs especially for pulse and Actual outcome:
blood pressure. Watched for changes.
R: an increase of pulse and blood pressure can Within 8 hours of student nurse and
indicate loss of circulation and covert bleeding. patient interaction:
2. Monitored platelet count.
R:low platelets denotes severe bleeding DAY 1 (March 2, 2017)
3. Monitored skin color and presence of bruises. Petechiae found on the upper right
R: Bruises indicate ruptured underlying blood arm
vessels.

Scientific Basis: NS1
antigen test (nonstructural protein
1), is a test for dengue, introduced
in 2006. It allows rapid detection
on the first day of fever, before
antibodies appear some 5 or more
days later. A positive result of NS1
antigen test implies that there is
an active infection caused by the
dengue virus inside the clients
body. A dengue virus attacks the
liver spleen and suppresses the
bone marrow. Bone marrow
suppression causes a decreased
production of the blood cells
especially the platelets. The
platelets are the ones responsible
for maintaining the integrity of the
blood vessels, if there is a
decreased production of these
blood cells, the blood vessels may
disrupt which leads to bleeding.
Source: Wiwanitkit, V. (2012).
The importance of accurate
diagnosis of dengue fever.
Future Virology, 7(1), 53-62.
4. Checked for unusual color of stool and urine.
R: urine that appears dark or smoky may indicate DAY 2 (March 3, 2017)
bleeding in the urinary tract. Black tarry stools
Petechiae still noted on the upper
may indicate bleeding in the upper GI tract and
hematochezia or presence of blood may indicate right arm
Laboratory findings for fecalysis -
bleeding in the lower GI tract.
occult blood testing came out positive
5. Encouraged to report for severe headache and
dizziness.
R: Headache or changes in neurological status
can indicate intracranial bleeding.
6. Encouraged to eat foods rich in Vitamin K such as
avocado, banana and sweet potato.
R: Vitamin K can help and promote to thicken
blood and increase clotting ability.
7. Maintained a safe environment for the patient
such as raising side rails.
R: to prevent bleeding due to a fall
8. Kept sharp objects away from patient
R: to avoid acquiring wounds
9. Encouraged to avoid aggressive toothbrushing
and use a soft-bristled toothbrush and avoid nose
picking.
R: Fragile tissues and altered clotting
mechanisms increase the risk of hemorrhage
even after a minor trauma.
10. Instructed to avoid forceful blowing, coughing,

Date identified: March 02, 2017
Risk for Injury related to possible
abnormal neuronal firing secondary
to dengue fever
Cues:
- History of generalized tonic
seizure
- Fever with a temperature of
37.6oC/axilla (no=36.5-
37.5oC/axilla)
- Lethargic
Scientific Basis: Dengue fever
activates the innate and adaptive
immune system in response to the
invasion of dengue virus. Innate
immune system refers to the WBC
production while adaptive immune
system refers to the production of
immunoglobulins (B-cell mediated)
and release of cytokines (T-cell
mediated). The cytokines stimulate
the release of pyrogens. Pyrogens
are responsible for resetting the
thermostatic set point of an individual
After 2 days of student nurse-patient
interaction, patient will be able to:
attain or sustains no injury
during seizure activity;
adhere with safety measures
and identifies hazards of non
compliance;
Will verbalize the importance of
lifestyle changes to reduce risk
factors and protect self from
injury.
sneezing and straining to have a bowel
movement.
R: These activities can damage mucous
membranes increasing the risk for bleeding.
11. Instructed to avoid chocolate colored foods.
R: patient may have a false positive for black tarry
stools.
Independent: After 8 hours of student nurse-patient
1. Keep objects away that could cause injury to the interaction:
patient during a seizure.
R: to protect the patient from injury. Day 1 (March 2, 2017)
2. Triage in observation room on bed. (padded side rails Patient sustains no signs of injury
up with bed in lowest position.) Patient did not experience a recurrence
R: minimize injury when seizure occurs while the of the seizure activity
patient is in bed.
Day 2 (March 3, 2017)
3. Explore with the SO the various stimuli that may
precipitate seizure activity Patient sustains no signs of injury
R: lack of sleep, flashing lights and prolonged Patient did not experience a recurrence
of the seizure activity
television viewing may increase brain activity that
.
may cause potential seizure activity
4. Maintain strict bed rest if prodromal signs or aura
experienced.
R: patient may feel restless to ambulate or even
defecate during aural phase, that inadvertently
removing
5. Maintained seizure precaution such as oxygen
apparatus and suction materials at bedside.
R: To be ready whenever the patient will have an
episode of seizure.
thereby producing fever. Fever
enhances the rate and magnitude of
neuronal firing which decreases the
seizure threshold. Seizure threshold
among children is lesser compared to
that of adults which is why seizures
are frequently manifested among
children with high fever.
Source: Baumann, R. J. (2016).
Pediatric febrile seizures. Retrieved
from http://emedicine.medscape.com.
Date identified: March 02, 2017
Risk for Fluid Volume Deficit
related to hyperthermia secondary to
dengue fever
Cues:
Increased temperature of
37.6oC/axilla (no=36.5-
37.5oC/axilla)
Scientific Basis: An increase in the
body temperature increases the
metabolism. Metabolism is the sum
of all the biochemical reactions in the
body. Two key ingredients of
metabolic reactions are water and
oxygen. Increased metabolism uses
more water and also makes you
breathe faster, to supply the extra
oxygen. The water lost during
metabolism and breathing is referred
Within 2 days of student nurse-
patient interaction,
The patient will be able to:
Increase oral fluid intake
Maintain balanced fluid input
and output
Can participate in activities
that would promote the
maintenance of adequate
fluid volume
1. Monitor and document vital signs especially BP and HR
R: Decrease circulating blood volume can cause
hypotension and tachycardia. A weak pulse or an
irregular rhythm may indicate electrolyte imbalance.
2. Assess skin turgor and oral mucous membranes for
signs of dehydration
R: Signs of dehydration are also detected through the
skin.
3. Assess alteration in mentation/sensorium (confusion,
agitation, slowed responses)
R: Alteration in mentation/sensorium may be caused by
abnormally low glucose, electrolyte abnormalities,
acidosis, decreased cerebral perfusion, or developing
hypoxia
4. Monitor fluid status in relation to dietary intake
R: Verifying if the patient is on a fluid restraint is
necessary
5. Urge to drink prescribed amount of fluid
After 8 hours of student nurse-patient
interaction:
Day 1 (March 2, 2017)
No signs of dehydration such as cold,
clammy skin, dry oral mucosa, sunken
eyeballs and pallor noted.
Patient is on NPO status which
prohibited her to take in any fluids
Day 2 (March 3, 2017)
No signs of dehydration such as cold,
clammy skin, dry oral mucosa, sunken
eyeballs and pallor still noted.
SO reported that client was able to
consume 500ml of water since 8 am
that morning to 3 pm
to as insensible water loss which may
lead to dehydration.
Source: Lemone, P. & Burke, K.
(2004). Medical surgical nursing:
Critical thinking in clients care (3rd
ed.). Upper Saddle River, NJ:
Pearson Prentice Hall.
Date Identified: 03/02/17
Imbalanced nutrition: more than
body requirements related to
excess body fat by skinfold or other
measurements secondary to
unhealthy eating habits as verbalized
by, Gana mn jud ni siya mokaon
maskin unsa miss unya pagustuan
rapud sa lola as manifested by IBW
result of 142% (moderate obesity).
Scientific Basis: Obesity is define
as an abnormal increase of fat in the
subcutaneous connective tissue
R: To avoid further complications and further
abnormalities
6. Aid the patient if he or she is unable to eat without
assistance, and encourage the family to assist with
feedings if necessary
R: Dehydrated patients are weak and unable to meet
prescribed intake independently
7. Plan daily activities
R: Planning conserves patients energy
Collaborative:
1. Administered IVF of D5LR 1L at 25 gtts/min.
R: to replace fluids and electrolytes and prevent
dehydration.
Within 2 days of student nurse- Independent: Day 1 (March 02, 2017)
patient interaction, the patient will:
1. Assessed weight; measure muscle mass, or Patient was instructed to take nothing
- Identify inappropriate calculated body fat by means of anthropometric by mouth as ordered by the physician.
behaviors and consequences measurements and growth scales.
associated with overeating or R: To provide information about effectiveness of Patient reported to have no appetite as
weight gain. therapeutic regimen and visual evidence of success verbalized by, I dont like to eat
of patients efforts. anything.
- Demonstrate change in
eating patterns and 2. Obtained a thorough history. No exercise was done due to
involvement in individual R: To assess the activities which predispose the weakness and fatigue
exercise program. client to her current condition.
3. Assessed the effects or complications of being Day 2 (March 03, 2017)
overweight.
R: Social complications and poor self-esteem may Patient can drink 1 glass of water per
also result from obesity. meal as reported by her mother and
has a reported improvement of her
under skin. Eating greater amounts of
food than body can use for energy
causes this deposition.
Source: Lemone, P. & Burke, K.
(2004). Medical surgical nursing:
Critical thinking in clients care (3rd
ed.). Upper Saddle River, NJ:
Pearson Prentice Hall.
Date identified: March 2, 2017
Activity Intolerance related to the
interference of nerve transmission
secondary to the intake of
Phenobarbital as manifested by
lethargic condition and a score of 4/5
on all extremities for muscle strength
(no=5/5)
Scientific Basis: Phenobarbital acts
on GABA receptors, increasing
synaptic inhibition. This has the effect
of elevating seizure threshold and
Within 2 days of student nurse-patient
interaction, the patient would be able to:
- Perform ADLs with minimal
assistance like feeding, toileting,
bathing, dressing and ambulation.
- Maintain/ increase muscle strength
and function of affected
compensatory body part.
appetite
4. Assessed dietary intake through 24-hour recall or
questions regarding usual intake of food groups. Patient can now stand with assistance
R: Permits appraisal of patients knowledge about
diet also.
5. Encouraged patient to eat only at a table or
designated eating place and avoid standing while
eating.
R: Techniques that modify behavior may be helpful
in avoiding diet failure.
6. Developed an appetite reeducation plan with
patient.
R: Signals of hunger and fullness often are not
recognized, have become distorted, or are ignored.
7. Promoted adequate and timely fluid intake and limit
fluids one hour prior to meal.
R: To reduce possibility of early satiety.
Independent: After 8 hours of student nurse-patient
1 Assisted in ambulating. interaction, the patient was able to:
R: phenobarbital causes drowsiness.
Day 1 (March 2, 2017)
2 Performed passive ROM of both right and left lower
extremities.
R: To prevent muscle atrophy Rest and sleep but still appears tired
3 Provided a conducive environment for sleep and rest and exhausted.
such as providing well ventilation, organizing
materials and minimize the noise Signs and symptoms of fatigue noted
R: To provide comfort and enhance relaxation such as weakness and slowed
movements.
4 Kept necessary things within reach.
R: To preserve oxygen and energy consumption
Day 2 (March 3, 2017)
reducing the spread of seizure
activity from a seizure focus. As it
acts on GABA receptors, it depresses
the sensory cortex,
decreases motor activity,
alters cerebellar function, and
produces drowsiness, sedation, and
hypnosis.
Source: Hodgson, B. & Kizior, R.
(2016). Saunders nursing drug
handbook. St. louis, MO: W.C.
Saunders Co.
Date identified: March 2,2017
Altered Comfort related to itching as
manifested by petechial rashes on
right arm with a verbalization of yes Verbalize reduce discomfort
its itchy.
Within 2 days of student nurse
patient interaction, the patient and
S.O would be able to:
R: Scratching stimulates histamine release which
produces more itching.
Identify methods to decrease itching
without scratching or rubbing the
skin.
5 Instructed Significant others to stay at the bedside
always Demonstrated increased tolerance to
R: To address immediate help and concerns needed. activity.
Was able to rest and sleep well.
6 Scheduled nursing activities like morning care, vital Was able to stand with assistance.
signs monitoring. ROM was still limited
R: To provide adequate rest periods.
Day 3 (March 4, 2017)
7 Scheduled nursing activities like morning care, vital
signs monitoring. Was able to do her usual activities
R: To provide adequate rest periods. such as drawing and making her
assignments.
Was able to sleep and rest well.
Day 4 (March 5, 2017)
Was able to do her usual activities
such as drawing and making her
assignments.
High energy was noted as
manifested by interested in talking
with the student nurses
Independent: After 8 hours of student nurse patient
1. Advised against scratching and instructed to apply interaction,
firm pressure or stroking with soft brush at sites of
itching instead of scratching. Day 1 (March 2, 2017)
the patient:
Verbalized feelings of persistent itching
2. Advised to keep the room with good ventilation and
moisture. the S.O:
R: Dry air makes the skin feel itchy, comfortable Identified methods to decrease itching of skin
 environment promotes relaxation.
3. Instructed S.O to let patient wear loose clothing.
R: Overdressing or rough clothes are too hot and
causes vasodilation that may irritate the skin.
such as not letting the patient scratch his
skin, providing daily baths using mild soap
and cool water, wearing loose clothing and
applying moisturizer.

4. Keep fingernails short. Day 2 (March 3, 2017)

R: Scratching with finger nails can excoriate the area the patient:
and increase skin damage. Verbalized feelings of reduced itching and
improvement in comfort
5. Provide distraction techniques such as music,
drawing, and massage.
R: Temporarily distract the patient from the itching
sensation.

6. Keeping the skin always moist.

R: This action prevents water loss, dry skin and itching
usually cannot be cured but can be controlled.

Date identified: March 2, 2017
Disturbed sleeping pattern related
to frequent monitoring by the
healthcare provider secondary to
hospital admission with a
verbalization of I feel distracted by
the people going in and out of the
room.
Scientific Basis: Sleep is required to
provide energy for physical and
mental activities.
Interruption/disruption in the
individuals pattern of sleep and
wakefulness may be temporary or
Within 2 days of 8 hours student
nurse-patient interaction, the patient
will be able to:
Sleep and rest with enough
time
Statements of feeling well
rested
Report improvement in quality
of sleep and pattern
1. Assessed for presence of physical or psychological
stressors such as pain and current illness.
R: Worry over personal problems or situations can
disrupt sleep.
2. Explained rationale of nursing intervention such as
frequent monitoring.
R: Reduces anxiety of patient concerning frequent
interruption of rest periods.
3. Discussed relaxation techniques such as listening to
music.
R: Decreases anxiety and may be used to facilitate
resting and sleeping
4. Provided quiet and comfortable environment such
After 8 hours of student nurse-patient
interaction:
Day 1 (March 2, 2017)
The patient reported that she was
unable to sleep well and was easily
aroused because of intermittent
monitoring of health care providers.
Day 2 (March 3, 2017)
The patient appeared well rested and
had an adequate hours of sleep with a
verbalization of I slept well today.
chronic which may result in both
subjective distress and apparent
impairment in functional abilities.
Sleep patterns can be affected by
environment, especially in hospital
care units. These patients experience
sleep interruptions/disturbances
secondary to the noisy and frequent
monitoring and treatments.
Source: Flaughter, M. (n.d.). The
importance of sleep: Promoting
restful sleep in patients as well as the
nurses who care for them. Retrieved
from http://nursing.advanceweb.com.
as using night light rather than overhead light
whenever possible, keeping beepers and alarms on
low volume and keeping the door closed.
R: Conducive environment helps patient to relax,
rest, and sleep.
5. Scheduled activities to be done.
R: Provides enough time to rest and sleep
6. Explore other sleep aids (warm bath or milk)
R: To promote wellness
7. Encourage client to urinate just before bedtime
R: To reduce discomfort and promote wellness