B.

PLANNING (NURSING CARE PLAN)

1.) HYPERTHERMIA

Assessment Nursing Scientific Objectives Interventions Rationale Expected

Diagnosis explanation Outcome

S>ø Hyperthermia Dengue Hemorrhagic Short term: >Establish good >to gain patient’s Short term:
related to Fever is potentially working condition trust
O> patient After 4 hours of The patient’s body
inappropriate deadly complication with the pt and
manifested: Nursing temperature shall
clothing factor that is characterized SO.
Interventions the have a maintained
>Flushed warm as evidenced by by high fever.
patient’ will be >Assess general >to have baseline normal body
skin decrease in Hyperthermia is an
maintaining a condition data temperature.
platelet count. abnormal rise in the
>Increase normal body
temperature of the >monitor v/s q
temperature.
Temp. of human body. Normal 1hour. >To have a

38.2OC body temperature is comparative data

98.6 OF or 37.5 OC. and check
CR:102bpm effectiveness of
Fever may not result
only from a treatment regimen
BP:60/30mmh
g70/40mmg disturbance of heat-

hg regulating
>provide TSB >to maintain a Long Term:
mechanism of the Long Term:
RR:25cpm normal body
body but also through the patient shall
After 4 days of temperature.
disturbances of the have experienced
NI, the patient
>irritability blood, the rate of will experience >to replace fluid no associated
breathing. Indeed no associated >Encourage loss complications
>Diaphoresis increase fluid
there are oral intake complications such as seizures
intake
patient may during periods of such as seizures >to boost body etc.
manifest: illness will result to etc. >Encourage food resistance to
further body rich in Vitamin C infection
 Increased
weakness impairing
PR >provide client >to prevent further
the patient’s ability to
 Increased safety injuries
perform usual
Body
routines and ADL’s
>maintain bed rest
temperatur
>to preserve
e of more >Administer energy
than Antipyretics as
38.0 C O
>To achieve
ordered
 Increased normal body
RR temperature if
 Seizure TSB did not work
 Muscle
rigidity
3.) INEFFECTIVE PERIPHERAL AND G.I. TISSUE PERFUSION RELATED TO DECREASE HGB CONCENTRATION IN THE
BLOOD

Assessment Nursing Scientific Objectives Interventions Rationale Expected

Diagnosis explanation Outcome

O> patient Ineffective Due to the Short term: >Assess the >to have baseline Short term:
manifested: Peripheral and replication of patient’s condition data
After 3 hours of The patient shall
gastrointestinal dengue virus in
>appears pale and Nursing > Monitor vital have
tissue perfusion the body, there >needed for ongoing
weak Interventions the signs demonstrated
related to could be comparison
patient’ will behaviors that
>flushed palms decrease hgb stimulation of
demonstrate >assess for possible will improve thee
and soles concentration in production of
behaviors that >early detection of tissue perfusion.
blood. kinine causing causative factors r/t
>Skin will improve the cause facilitates
increase vascular temporarily
Temperature tissue perfusion. prompt, effective
permeability impaired arterial
changes treatment
leading to blood flow

>Hypotension capillary damage. >To provide non-

pharmacologic
Thus will cause >Provide AM care
interventions
>Abdominal Pain
internal bleeding.
This was >loss of peripheral
S:The patient may >Monitor quality of
manifested pulses must be
verbalize all pulse
through flushed reported or treated
Abdominal Pain, immediately
palms and soles
Nauseousness and Long Term:
and appearance of >to increase cellular
headache Long Term:
brownish purplish
O: The patient rashes on the After 1 days of >maintain optimal oxygen supply The patient shall
may manifest the extremities NI, the patient cardiac output have
ff.: will demonstrate >To maintain clients demonstrated
increase tissue >Maintain thermo normal temperature increase tissue
Abdominal
perfusion AEB regulated perfusion AEB
Distention
vital signs within vital signs within
>To increase blood
Vomiting normal range normal range
>Position patient in pressure
hypoactive BS trendelenburg
position
Skin Temperature
Changes >to evaluate the
>review lab values
importance of NI’s
Edema and note customary
given and provide
baseline data
BP changes comparison by
current findings
Altered Sensation

Weak pulse

2. DEFICIENT FLUID VOLUME RELATED TO ACTIVE FLUID LOSS AS EVIDENCE BY BLEEDING

Assessment Nursing Scientific Objectives Interventions Rationale Expected

Diagnosis explanation Outcome

S>ø Deficient Fluid Volume Short term: > Assess general >To have a Short term:
Fluid Volume deficit or condition baseline data
O> patient manifested related to After 4 hours of The patient’s
Hypovolemia
the following: active fluid Nursing >Obtain pt. History >To ascertain the mother shall have
Irritable loss as occurs from a Interventions, probable cause of verbalized
evidence by loss of body fluid the patient’s fluid disturbance understanding of
Weakness bleeding
or the shift of mother will causative factors
rd
>To determine if
Hypotension fluids into the 3 verbalize > Evaluate fluid status and purpose of
pt. is on fluid
space, from a understanding of in relation to diet individual
Pale in appearance restriction
reduced fluid causative factors therapeutic
>Monitor and Note
Temp. of 38.2OC intake and is and purpose of >To have a interventions and
VS Q1
cause by bleeding individual comparative data medications.
CR:102bpm
leading to shock. therapeutic and to monitor
BP:60/30mmhg  DHF Virus that interventions and client’s response to
70/40mmghg destroys the medications. treatment regimen
platelets which
RR:25cpm
lead in to >Concentrated
bleeding. The Long Term: urine denotes fluid Long Term:
loss of blood >Assess color and deficit
Pt may manifest After 2 days of the patient shall
from the system amount of urine
nursing >to determine have maintained
Decreased Urine may lead to
interventions the hydration status fluid volume at a
Output shock.
patient will >Assess Skin turgor functional level
Hypotension and mucous
maintain fluid as evidence by
Hemoconcentration membranes for signs
volume at a >Results may urine output
Weakness of DHN
functional level suggest fluid deficit greater than
Change in mental
as evidence by and to give proper 30mL,
>Monitor Serum
status
urine output medications and normotensive BP,
Electrolytes and urine
Dry mucous
greater than Heart rate is
osmolality and report
membranes 30mL, abnormal values interventions normal,
Tachycardia normotensive consistency of
Tachypnea BP, Heart rate is >Oral fluid weight and
Edema normal, replacement is normal skin
Bleeding consistency of >If not on NPO turgor
indicated
Decrease skin turgor weight and encourage pt. to drink

Decrease venous normal skin prescribed fluid

> To prevent
filling turgor amounts
fatigue and further
weakness
>Plan daily activities
and involve pt. and
>Promotes interest
SO in drinking

>Provide oral hygiene >To provide

nonpharmacologic
>Provide comfort management

measures >thus dengue may

lead to shock

>WOF for edema,

bleeding, narrowing
of Pulse pressure and
>May require if
Hypotension bleeding at the GI
is happening and to
>Administer promote cloting
factor (if FFP)
parenteral fluids as
ordered plus blood
>To commence
 products as prescribed replacement of
fluids
>Give
supplementary )2
therapy as prescribe

4.) RISK FOR INJURY R/T ABNORMAL BLOOD PROFILE AS EVIDENCED BY DECREASE PLATELET COUNT

Assessment Nursing Scientific Objectives Interventions Rationale Expected

Diagnosis explanation Outcome

S>ø Risk for injury Risk of Injury as Short term: >Establish rapport >to gain patient’s Short term:
r/t abnormal a result of trust
O> After 4 hours of >Assess level of The pt shall have
blood profile as environmental
Nursing consciousness and >assist in demonstrated
patient manifested evidenced by conditions
Interventions, pt cognitive level determining pt. ‘s techniques
the following decrease platelet interacting with
will demonstrate ability to protect behavior, lifestyle
which put his at count. the individuals
techniques self and comply changes to risk
risk for injury adaptive and
behavior, with required self factors and protect
defensive
Low platelet count lifestyle changes protective actions self.
resources. It is
Abnormal blood to risk factors
also because of > Minimizes
profile and protect self. >Provide safe
the infection of injury to occur
Tissue Hypoxia environment (pad,
DHF I Virus that
side rails, prevent
destroys the
Pt may manifest: falls)
platelets which
Sensory place the patient > Observe for each
> Permits
dysfunction at risk of stool color,
Broken Skin bleeding. When Long Term: consistency and detection of
Malnutrition the blood vessels amount bleeding in GI
After 1 days of
Low platelet count are cut or damage tract mechanism
NI, the patient’
Abnormal blood , the loss of blood Long Term:
will be free from >to detect and
profile from the system >Observe for
injury. prevent further the patient shall
Tissue Hypoxia must be stop hemorrhagic
injury have been Freed
before shock and manifestation,
from injury.
possible death ecchymosis,
may occur. This epistaxis, Petechiae,
is accompanied and bleeding gums
by solidification
>Encourage intake > Promotes
of the blood, a
of foods with high healing and boost
process called
content of Vit. C the resistance of
coagulation or
the body against
clotting. If the
value should stop infection

below normal,
(150,000 > To obtain
-450,000 g/dl), > Assess pt’s baseline data
there is a danger condition and
of uncontrolled monitor vital signs.
bleeding because
> Provide comfort
of the essential
measures, such as > To promote
role that platelets
stretching bed relaxation and
 have in blood linens. alleviate.
clotting.
> Avoid SC, IM
route of injection as
possible > Minimizes
tendency of
trauma or bleeding

5.) RISK FOR CONSTIPATION R/T IRREGULAR DEFECATION HABITS AEB DEFECATE ONCE OR TWICE PER WEEK

Assessment Nursing Scientific Objectives Interventions Rationale Expected

Diagnosis explanation Outcome

S=Ø Risk for Irregular Short term: >Provide >To ease Short Term:
constipation defecation habits comfortable patient’s anxiety
After 3 hrs of Patient shall have
related to of one or two environment and to help the
nursing demonstrate
O= patient manifested irregular times per week interventions patient recover behavior changes to
by: defecation may cause the patient will faster for proper developing problem
habits as stool to harden demonstrate hygiene of the
>irregular defecation
evidence by and dry. It may behaviors patient
habits
defecate once also cause changes to
>For proper
inadequate toileting or twice per infection which developing
hygiene of the
week may lead to problem >Provide comfort
>recent patient
constipation measures by AM
environmental
care, changing the
changes
linen and touch
>change in usual therapy
eating pattern

>ignoring urge to >To avoid patient

>Provide safety by Long Term:
defecate from injury
placing pillows at
Patient shall have
S: The patient’s SO the side of the bed
improve her bowel
may verbalize that the
Long term: >To have pattern
patient is not >VS monitor and baseline data
defecating for more After 1 day of change
than 3 days nursing >Reflecting
>Auscultate
interventions bowel activity
abdomen for
patient will
presence, location
O: Patient may improve her
and characteristics
manifested by: bowel pattern
of bowel sounds
>dehydration >Review
medication
>electrolyte >For impact
imbalance effect of change
in bowel function
>decrease motility of
gastro intestinal tract >To improve
>Encourage balance
consistence of the
>hemorrhoids fiber and bulk habit
stool and
>Insufficient physical facilitate passage
activity through colon

>Promote adequate >To promote soft

fluid intake, stool and
including water and stimulate bowel
high-fiber fruit activity
juice; also suggest
drinking warm fluid

>Ascertain
frequency, color,
consistence, amount >Provide as
of stools baseline of
comparison,
promotes
>Educate client/SO recognition of
about safe and risky
practice for changes
managing
constipation >Information can
help client to
>Review medical/
make beneficial
surgical history
choices when
needed

>To identify
condition
commonly
>Review associated with
appropriate use of constipation
medication. Discuss
client’s current
medication regimen >To determine if
with physician drugs
contributing to
constipation can
be discontinue or
change