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NURSING DIAGNOSI S Ineffectiv e Tissue Perfusion related to decrease d Hemoglob in in the blood secondary to DHF
OBJECTIV ES
NURSING INTERVENTI ON
RATION A-LE
OUTCOM EVALUTIO E N CRITERI A The patient shall have demonst rated behavior s to improve circulati on.The shall have demontr ated increase d perfusio n as appropri ate.
Subjective: none Objective: -Decrease WBC -Decrease platelet -Decrease hemoglobin -Decrease capillary refill time
After 2 days of nursing interventi on, the patient will demonstr ate increase perfusion as appropria te.
Scientific Basis: Hemoglob in count is used to measure the oxygen carrying capacity of the blood. Hemoglob in carries oxygen. Therefore when the Hemoglob in is low, there is also a decrease in oxygen that reaches
Independent: -Establish -to gain rapport patient s trust -Monitor -to patients obtain vital signs baselin e data -Assess -to patients know condition contrib uting -Note for factors presence of -to bleeding determi ne risk -Elevate for head of bed anemia -to promot e -Instructed proper patient to circulati avoid tiring n activities -to -Encourage decreas light e ambulation cardiac work load -Encouraged -to use of enhanc relaxation e technique venous return -to Dependent: decreas -Perform e Homans tension sign and
anxiety level -to determi ne presenc e of thromb us formati on -to treat underly ing cause
Discharge Plan: 8/9/12 @ 9:00AM MEDICATION: Continue taking prescribe medication for the patient on exact dosage, time, and frequency Instruct the patients S.O to follow the instruction when administering meds. Advice the S.Os not to leave the patient during giving of medication. Advice the S.O not to stop intake of prescribed meds, unless approved by the physician. Stress out the importance in taking the medication religiously. Instructed S.O not to give aspirin and NSAIDs, because they increase the risk of bleeding and that any medicines that decrease platelet count should be avoided EXERCISE:
Instructed patient to avoid excessive activities that may result to
stress. Just advised to perform range of motions and repetitive body movements for promotion of optimum health. Reminded
about the need for health promotion activities such as reading, watching T.V, Bed rest is advisable during the re-occurrence of fever phase.
Instruct to drink plenty of water or fluids that are available at
physician once a while to monitor patients condition and for detection of recurrences and other complications that may arise on it. DIET: Instructed the family members to give the client protein rich foods such as meat, fish, eggs and dairy products. SPIRITUAL: Encouraged family to strengthen their faith to the Almighty Father. Encouraged to pray the Rosary with the rest of the family for Gods guidance.
PROGNOSIS: With early and aggressive care most patients recover from dengue hemorrhagic fever. However, half of untreated patients who go into shock do not survive.
GRADING THE SEVERITY OF DENGUE FEVER: Grade 1:>fever >non-specific constitutional symptoms such as anorexia, vomiting and abdominal pain>absence of spontaneous bleeding>positive tourniquet test Grade 2:>signs and symptoms of Grade 1: plus>presence of spontaneous bleeding: mucocutaneous, gastrointestinal
Grade 3:>signs and symptoms of Grade 2 with more severe bleeding: plus>evidence of circulatory failure: cold, clammy skin, irritability, weak tocompressible pulses, narrowing of pulse pressure to 20 mmhg or less, coldextremities, mental confusion Grade 4:>signs and symptoms of Grade 3, declared shock, massive bleeding, pulse lessand arterial blood Pressure = 1 mmhg (Dengue Syndrome/DS)