NURSING CARE PLAN

Assessment Subjective: Hindi po siya makatulog ng maayos. As verbalized by the father. Objective: weak with 3-5 hours of sleep with dark circles under eyes frequent yawning Nursing Diagnosis Sleeping pattern disturbance related to change in environment. Scientific Explanation Illness Hospitalization Noisy Environment Sleep Depriavation Nursing Goal Short Term Goal: After 1-2 hours of rendering nursing care the patient will: a) verbalize understanding of sleep disturbance b) identify individually appropriate interventions to promote sleep Long Term Goal: Within 2-3 days of rendering nursing care, the pt will a) improvement in sleep/rest pattern b) report increased sense of wellbeing and feeling rested Nursing Intervention Observe and obtain feedback from patient/SOs regarding usual bedtime, rituals/routines, number of hours of sleep, time of arising, and environmental needs. Determine patients/SOs expectations of adequate sleep. Identify circumstances that interrupt sleep and frequency. Rationale To determine usual pattern and provide comparative baseline Evaluation Goal is met. Mayat mit ti turog na. As verbalized by the mother of the patient. makaturog akon. As verbalized by the patient. With 8-10 hrs of sleep. Alive in communicating At ease Absence of dark circles under eyes Absence of yawning during the day

To provide opportunity to address misconceptions or unrealistic expectations. To enhance pts ability to sleep To enhance pts ability to fall asleep, reinforce that bed is a place to sleep, and promote sense of security for child.

Discuss or implement effective age appropriate bedtime rituals like - going to bed at the same time each night - drinking warm milk - favorite blanket, pillow or toy Encourage participation in regular exercise program during day

Recommend inclusion of bedtime snack - Mild juice - Crackers] - Protein source such as cheese/peanut butter

To aid in stress control/release of energy. Exercise at bed time may stimulate rather than relax patient and actually interfere with sleep. To reduce sleep inteference from hunger or hypoglycemia

Provide for a childs sleep time safety - Bed in low position - Non-plastic sheet Recommend midmorning nap if one is required.

To promote more time in sleeping at night

Napping especially in the afternoon, can disrupt normal sleep pattern.

NURSING CARE PLAN

Assessment Subjective: Ang init nya as verbalized by the father of the patient. Sumasakit nga rin po ang ulo ko as verbalized by the pt. Objective: with flushed skin; warm to touch Temp = 38.9oC Nursing Diagnosis Hyperthermia related to increased metabolic rate secondary to dengue fever as evidenced by flushed skin; warm to touch and temp of 38.9oC Scientific Explanation Chemostatic response Release of chemical mediators (pyrogen) Stimulation of thermoregulation in hypothalamus Increase body temperature FEVER Nursing Goal Short Term Goal: After 3-5 hours of rendering nursing care the pt/SOs will demonstrate behaviors to monitor and promote normothermia. Long Term Goal: Within 2-3 days of rendering nursing care, the pt will maintain core temperature within normal range of 36.5oC to 37.5oC. Nursing Intervention Monitor core temperature Rationale To monitor pts condition To decrease body temperature. Evaporation is decreased by environmental factors of high ambient temperature as well as body factors producing loss of ability to sweat or sweat gland dysfunction. Evaluation Goal is met. Wala na siyang lagnat. Effective yung pagpupunas sa kanya and yung gamot. As verbalized by the mother of the patient. Temp = 37.5oC

Provide TSB

Note presence or absence of sweating as body attempts to increase heat loss evaporation, conduction, and diffusion.

Promote surface cooling by means of: - undressing - cool environment or fans - cool/tepid sponge baths or

To promote heat loss by means of: - radiation &

immersion - local ice packs, especially in the groin and axillae

Administer medications Maintain bedrest

conduction - convection - evaporation & conduction - areas of high blood flow To decrease body temperature To reduce metabolic demands or oxygen consumption To meet increases metabolic demands

Provide high-calorie diet or parental nutrition Discuss importance of increase fluid intake

To prevent dehydration

NURSING CARE PLAN

Assessment Subjective: Nanghihina nga siya. Tignan mo ang tamlay niya bago pa kami dumating dito ganyan na siya. as verbalized by the Father of the patient. Objective: With dry skin and mucous membrane Temp = 38.2oC diaphoresis

Nursing Diagnosis Fluid volume deficit related to failure of regulatory mechanism secondary to fever as evidenced by dry skin and mucous membrane, temp of 39.1oC..

Scientific Explanation Injured platelets

Nursing Goal Short Term Goal: After 1-2 hours of rendering nursing care the pt/SOs will: a) verbalize understanding of causative factors and purpose of individual therapeutic interventions and medications. b) Demonstrate behaviors to monitor and correct deficits as indicated. Long Term Goal: Within 2-3 days, the pt will maintain fluid volume at a functional level as evidenced by stable vital signs, moist mucous membranes and good skin turgor.

Nursing Intervention Assess vital signs; note strength of peripheral pulse.

Rationale To evaluate degree of fluid deficit.

Evaluation Goal is met. Ah, o sige ilagay ko na lang itong tubig sa my mesa malapit sa kanya para madali niyang abutin kapag nauuhaw na siya. As verbalized by the mother of the patient. With moist mucous membrane With good skin turgor Temp = 37.5oC

Activation of kinin system

Note physical signs of dehydration and determine customary and current weight.

To evaluate degree of fluid deficit.

Increase vascular permeability

Extravasations of fluid

Establish 24-hour fluid replacement needs and routes to be used.

To prevent peaks/valleys in fluid level.

dehydration

Note patient preferences regarding fluids and foods with high fluid content.

To correct or replace losses to reverse pathophysiological mechanisms. For the pt to easily grab the fluid whenever hes thirsty.

Keep fluids with patients reach and encourage frequent intake as appropriate. Administer IV fluids within pts reach and encourage frequent intake as appropriate Reduce bedding or clothes, provide tepid sponge bath.

To replace losses and prevent dehydration

To decrease severe fever and elevated metabolic rate.

To promote comfort

Change position frequently.

and safety.

Discuss factors related to occurrence of dehydration. Identify actions patient may take to correct deficiencies.

To promote wellness. To promote wellness.

NURSING CARE PLAN Assessment Subjective Cues: -Masaki ang tiyan koAVB the patient. Objective Cues: -abdominal pain 4/5 -diaphoresis -facial grimace -guarding behavior Nursing Diagnosis Abdominal pain related to inflammation of the liver. Scientific Explanation Replication of Dengue Virus Entry of infection to the liver Dengue Fever Virus Targets Liver Cells Infection produces Hepatomegaly Abdominal Pain Planning Short Term Goal -After 3 hours of nursing intervention, the patient will Nursing Intervention Rationale Evaluation

NURSING CARE PLAN

Assessment Subjective: Nahihilo ako pag tumatayo akoAVB the patient. Objective: -looks weak and pale -anorexic -with presence of bleeding presence of rashes on both upper and lower extremities Decrease appetite -Vital signs: T-39.1oC Hgb:12.9g/dl

Nursing Scientific Planning Nursing Intervention Diagnosis explanation *Short- term goal Risk for Entry of pathogens *assessed patient and monitored After 1-2 minutes of ineffective in the bloodstream vital signs nursing intervention, the peripheral significant others will tissue Blood will verbalize understanding perfusion interfere in the of the patient/s condition related to component and will demonstrate interruption of *explain to the significant others behaviors that can blood Platelet adhesion about the disease process improve pts circulation components and reduction Platelet *Encouraged to provide quiet After 8 hours of nursing of blood flow destruction environment, restful atmosphere intervention the patient due to >switch off unnecessary light will: *maintain normal vital bleeding Decrease platelet signs secondary to count >T-37-37.5 systemic viral infection Thrombocytopenia *will improve appetite *Positioned patient in a high and will consume atleast Bleeding fowlers of the meals served. tendencies *will increase fluid *Keep needed things within intake and will consume Decrease Hgb, reach atleast 500-600 ml of fluids within 8 hours Risk for infective peripheral tissue LONG TERM GOAL: *Schedule activities and routines perfusion like vital signs taking after a 2-3 days the patient will free from risk of Body weakness *Always assist patient, ineffective encourage SO not to live him for
peripheral tissue

Rationale *this will serve as a baseline data

Evaluation Goal met as evidenced by: -Significant others verbalized understanding of the patients condition and they demonstrated behaviors that improved patients circulation. -showed a stable vital signs of: Temp=37.5oC

*enhances venous return *To provide quiet environment that is conducive for rest and sleep to decrease oxygen consumption *To facilitate lung expansion *To avoid fatigue and increase oxygen consumption *To avoid rest disturbance *To reduce risk of accidents like falls

perfusion as evidence by: *normal urine output *(-) pale and weak *increase appetite and * Will able to consume all the meals served

long *Encourage SO to provide patient foods rich in IRON like eggs, fruits, meat like liver and vegetables *Stress the importance of taking foods rich in vitamin C like citrus, apple, guava, oranges etc. COLLABORATIVE: *administered Paracetamol for fever as ordered, 250mg/ml 7.5 ml q4hours
*on daily CBC

related to dizziness *To promote synthesis of hemoglobin

*Vitamin C enhances Iron absorption and it boost immune system