Ncp for Dengue

Assessment  Subjective “Ang init init ng kapatid ko kapag hinahawakan” As verbalized  by the patient’s patient’s sister.

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Objective - V/S taken as follows T- 38 degree celcius PR- 88 bpm RR-22 cpm BP-110/70 mmHg - Flushed skin - Warm to touch

Diagnosis Hyperthermia related to inappropriate clothing factor as evidenced by decrease in platelet count secondary to dengue hemorrhagic fever.

Planning After 2 hours of nursing intervention client will be able to maintain core temperature within normal range as evidenced by: - body temperature is lowered to 37 degree celcius.

Inference Body temperature elevated above normal level that is usually caused by several factors related to illness. As inoculation occurs, proliferation of virus follows and once the virus starts to grow in number, it will soon reach it pathogenic level that will result into pyrexia or fever as a defense mechanism of the body.

Reference: Nurse’s pocket guide by Marilyn Doeges10th edition

Implementation Independent: - Provide tepid sponge bath

Rationale -Heat loss by means of evaporation and conduction.

-Promote surface cooling by means of undressing

-Heat loss by means of radiation and conduction

- Provide cool environment

-Heat loss by means of convection

-Maintain bed rest or minimize movement

- To reduce metabolic demands of  oxygen consumption

- Discuss - To prevent importance dehydration of adequate fluid intake particularly to the parents. - Strictly monitor temperature

- To know if the  patient’s temperature went down to the normal

Evaluation After 4 hours of  nursing intervention goals and objectives was met as evidenced by: -Body temperature lowered to 37 degree celcius.

value. -Increase fluid intake

- To lower the temparature

Dependent: Administer paracetamol as prescribed by the physician.

- To alleviate the fever of the patient.

Collaborative: Refer to the physician if the temperature still higher to normal range.

- To monitor  patient’s condition.

Assessment  Subjective “Dumudugo yung labi ng kapatid ko” As verbalized by the  patient’s sister  Objective -Weakness and irritability -Restlessness -V/S taken as follows: T- 38.1 PR- 90 bpm R- 22 cpm BP- 110/70 mmHg

Diagnosis Risk for hemorrhage related to altered clotting factor.

Planning -After 3 hours of nursing interventions, the client will be able to demonstrate behaviors that reduce the risk of  bleeding

Inference Most dengue infections result in relatively mild illness, but some can progress to dengue hemorrhagic fever. With dengue hemorrhagic fever, the blood vessels start to leak  and cause bleeding from the nose, mouth, and gums. Bruising can be a sign of  bleeding inside the body. Without prompt treatment, the blood vessels can collapse, causing shock  (dengue

Implementation -Assess the signs and symptoms of  GI bleeding. -Check  for secretions. -Observe color and consistency of stools or vomitus.

Rationale -The GI tract is the most usual source of bleeding of its mucosal fragility

-Observe for presence of petichiae, ecchymosis, bleeding from one more sites.

-Sub-acute disseminate dintravascular coagulation may develop secondary to altered clotting factor.

-Monitor pulse, BP

-An increase in pulse with decrease BP can indicate loss of circulating blood volume

-Note changes in level of consciousness.

-Changes may indicate cerebral perfusion problems.

-Encourage use of  soft soft toothbrush. toothbru sh. Avoid straining in stool, and forceful nose blowing.

-Minimal trauma can cause mucosal bleeding

Evaluation -After 3 hours of nursing nursin g interventions, the client’s sister is able to demonstrate behaviors that reduce the risk  of bleeding.

shock  syndrome).

-Use small needles for injections. Apply pressure to veni puncture sites for longer than usual. Dependent: Don’t administer  aspirin.

-Minimize damage to tissues, reduce risk for bleeding and hematoma.

- To prevent spontaneous bleeding.

Collaborative: Check for platelet count. Check for hematocrit. Report to physician if  there’s a continuous bleeding.

-To know the patency of the hematocrit.

Assessment Subjective: “Sinasabi ng kapatid ko masakit daw tapos tinuturo niya yung tyan niya” As verbal ized by the the patient ’s sister. Objective: Facial grimace Clench Clenching ing of f ist s Pain scale of 5 out of 10. Vital Signs: BP-110/70 PR-88 RR-22 T-37.6 VAS-5 out of 10

Diagnosis Acute pain and discomfort related to dengue hemorrhagic fever. As evidence by VAS of 5 out of  10.

Planning Long term: After 2 hours of nursing interventions, the the client w ill be able to: a. Verbalize reports that provide relief. b. Demonstrate use of  relaxation skills and diversional activities as indicated for individual situation. Short term: After 30 minutes of  nursing intervention the patient can: a. Report pain is relieved/  controlled from a pain scale of 5 to 1 out of 10.

Inference Pain modulation refers to the function of  neural cells to inhibit, reduce, or dampen the intrinsic modulatory activity of the central nervous system, thus reducing the painful stimuli. Perception is the conscious awareness, usually localized in certain areas of  the body. Level of pain perception depends on factors such as personal experiences, immediate environment, and sociocultural influences. influences.

Implementation Independent 1. Assess client’s response to pain:

-Perform pain assessment each time pain occurs.

Rationale To rule out worsening of  underlying condition/  development of  complications Pain is subjective and cannot be felt by others

Observations -Accept client’s may not be description of  congruent with pain verbal reports. -Observe nonverbal cues Usually -Monitor vital altered in signs acute pain

2. Assist client to explore methods for alleviation/cont rol of pain: -Work with client to prevent pain.

Evaluation After 2 hours of nursing interventions, the client was able to: a. Report that her pain was reliev ed from from a pain scale of 5 to 1 out of 10. b. Demonstrate duse of  relaxation skills and diversional activities.

-Provide quiet environment, calm activities -Provide comfort measures like change of  positions. Dependent: Administer pain medicines Nuprin as  – Nuprin prescribed by the physician. Collaborative: Check results of the platelets of the patient if  it’s already higher than the previous laboratory.