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PLANNING (NURSING CARE PLANS) Problem No.

1 Hyperthermia Assessment S> O> patient manifested: >Flushed warm skin >Increase Temp. of 38.5 C >irritability >Diaphoresis patient may manifest:

Nursing Diagnosis Hyperthermia related to inappropriate clothing factor as evidenced by decrease in platelet count.

Scientific explanation Dengue Hemorrhagic Fever is potentially deadly complication that is characterized by high fever. Hyperthermia is an abnormal rise in the temperature of the human body. Normal body temperature is 98.6 F or 37.5
O O

Objectives Short term: After 4 hours of Nursing Interventions the patient will be maintaining a normal body temperature.

Interventions >Establish good working condition with the pt and SO. >monitor v/s q 2hours. >provide TSB

Rationale >to gain patients trust

Expected Outcome Short term: The patients body temperature shall have a

>to have baseline data >to maintain a normal body temperature.

maintained normal body temperature.

Long Term: After 4 days of NI, the patient will experience no associated complications such as seizures etc. >Encourage food rich in Vitamin C >to boost body resistance to infection >Encourage increase fluid intake >to replace fluid loss Long Term: After 4days of NI, the patient will experience no associated complications such as seizures

Increased PR Increased RR Seizure Muscle rigidity

C. Fever may

not result only from a disturbance of

heat-regulating mechanism of the body but also through disturbances of the blood, the rate of breathing. Indeed there are oral intake during periods of illness will result to further body weakness impairing the patients ability to perform usual routines and ADLs

>provide client safety

>to prevent further injuries

etc.

>maintain bed rest

>to preserve energy

Problem No. 2 ineffective tissue perfusion related to decrease hgb concentration

Assessment S> O> patient manifested: >appears pale and weak >flushed palms and soles

Nursing Diagnosis ineffective tissue perfusion related to decrease hgb concentration

Scientific explanation Due to the replication of dengue virus in the body, there could be stimulation of production of kinine causing increase vascular permeability leading to capillary damage. Thus will cause internal bleeding. This was manifested through flushed palms and soles and appearance of brownish purplish rashes on the

Objectives Short term: After 3 hours of Nursing Interventions the patient will demonstrate behaviors that will improve thee tissue perfusion.

Interventions > Establish good working condition with the pt and SO >Assess the patients condition > Monitor vital signs

Rationale >to gain patients trust

Expected Outcome Short term: After 3 hours of Nursing Interventions the patient shall

>to have baseline data

have demonstrated behaviors that will improve thee

>needed for ongoing comparison

tissue perfusion. Long Term: After 2-3 days of NI, the patient shall have demonstrated increase tissue perfusion AEB normal Hgb level count

Long Term: After 2-3 days of NI, the patient will demonstrate increase tissue perfusion AEB normal Hgb level count >assess for possible causative factors r/t temporarily impaired arterial blood flow >Monitor quality of all pulse

>early detection of cause facilitates prompt, effective treatment

>loss of peripheral pulses must be reported or

extremities

treated immediately >maintain optimal cardiac output >review lab values and note customary baseline data >to increase cellular oxygen supply >to evaluate the importance of NIs given and provide comparison by current findings

Problem # 3: Risk for injury r/t abnormal blood profile as evidenced by decrease platelet count Assessment Nursing Diagnosis Scientific explanation Objectives Interventions Rationale Expected Outcome

S> O> patient manifested the following which put his at risk for injury

Risk for injury r/t abnormal blood profile as evidenced by decrease platelet count.

Risk of Injury as a result of environmental conditions interacting with the individuals adaptive and defensive resources. It is also because of the infection of DHF I Virus that destroys the platelets which place the patient at risk of bleeding. When the blood vessels are cut or damage , the loss of blood from the system must be stop before shock and possible

Short term: After 4 hours of Nursing Interventions, pt will demonstrate techniques behavior, lifestyle changes to risk factors and protect self. Long Term: After 1 days of NI, the patient will be free from injury.

>Establish rapport

>to gain patients trust

Short term: After 4 hours of Nursing Interventions, pt will have demonstrate techniques behavior, lifestyle changes to risk factors and protect self. Long Term:

>Assess level of consciousness and cognitive level

>assist in determining pt. s ability to protect self and comply with required self protective actions

Low platelet count Abnormal blood profile Tissue Hypoxia

Pt may manifest

Sensory dysfunction Broken Skin Malnutrition

>Provide safe environment (pad, side rails, prevent falls) > Observe for each stool color, consistency and amount >Observe for

> Minimizes injury to occur

After 1 days of NI, the the patient will have been free from

> Permits detection of bleeding in GI tract > Indicate

injury.

death may occur. This is accompanied by solidification of the blood, a process called coagulation or clotting. If the value should stop below normal, (150,000 -450,000 g/dl), there is a danger of uncontrolled bleeding because of the essential role that platelets have in blood clotting.

hemorrhagic manifestation, ecchymosis, epistaxis, Petechiae, and bleeding gums

altered clotting mechanism

>Encourage intake of foods with high content of Vit. C

> Promotes healing and boost the resistance of the body against infection

> Assess pts condition and monitor vital signs. > Provide comfort measures, such as stretching bed

> To obtain baseline data

> To promote relaxation and alleviate .

linens.

> Avoid SC, IM route of injection as possible

> Minimizes tendency of trauma or bleeding

Problem # 4: Risk for constipation related to irregular defecation habits as evidence by defecate once or twice per week Assessment S= Risk for O= patient manifested by: irregular defecation habits inadequate toileting recent environmental changes >change in usual eating pattern >ignoring urge to defecate After 2 hrs of nursing interventions patient will Patient may manifested by: improve her bowel pattern Provide safety by placing pillows at the side of the bed To avoid patient from injury LT: constipation related to irregular defecation habits as evidence by defecate once or twice per week Irregular defecation habits of one or two times per week may cause the stool to harden and dry. It may also cause infection which may lead to constipation After 3 hrs of nursing interventions patient will demonstrate behaviors changes to developing problem Provide comfort measures by AM care, changing the linen and touch therapy For proper hygiene of the patient Patient shall have improve her bowel pattern LT ST Provide comfortable environment To ease patients anxiety and to help the patient recover faster for proper hygiene of the patient Patient shall have demonstrate behavior changes to developing problem ST Nursing Diagnosis Scientific explanation Objectives Interventions Rationale Expected Outcome

>dehydration >electrolyte imbalance >decrease motility of gastro intestinal troat >hemorrhoids Insufficient physical activity Auscultate abdomen for presence, location and characteristics of bowel sounds Reflecting bowel activity VS monitor and change To have baseline data

Review medication

For impact effect of change in bowel function

Encourage balance fiber and bulk habit

To improve consistence of the stool and facilitate passage through colon

Promote adequate fluid intake, including water and highfiber fruit juice; also suggest drinking warm fluid

To promote soft stool and stimulate bowel activity

Ascertain frequency, color, consistence, amount of stools

Provide as baseline of comparison, promotes recognition of changes

Educate client/SO about safe and risky practice for managing constipation

Information can help client to make beneficial choices when needed

Review medical/ surgical history

To identify condition commonly associated with constipation

Review appropriate use of medication. Discuss clients current medication regimen with physician

To determine if drugs contributing to constipation can be discontinue or change

Problem # 5 Impaired tissue integrity related to mechanical and chemical factor of IV infusion and blood test; secondary to haematoma as evidence by collection of blood on the upper extremities. Nursing Scientific Expected

Assessment S= O= patient manifested by: pallor haematoma on both upper extremities weakness impaired circulation damage tissue

Diagnosis Impaired tissue integrity related to mechanical and chemical factor of IV infusion and blood test; secondary to haematoma as evidence by collection of blood on the upper extremities.

Explanation Hematoma is a localized collection of blood, usually clotted, in a tissue or organ. Hematomas can occur almost anywhere on the body. In minor injuries, the blood is absorbed unless infection develops. One of the signs of haematoma is collection of blood in the peripheral area it may be seen in the upper extremities. Mechanical and chemical factors like IV infusion

Objectives ST After 4 hrs of nursing interventions patient will demonstrate behavior to reduce the hematoma LT After 2 weeks of nursing interventions presence of hematoma will be reduce

Interventions Provide comfortable environment

Rationale To ease patients anxiety and to help the patient recover faster for proper hygiene of the patient ST

Outcome

Patient shall have demonstrate behavior to reduce hematoma LT Patient shall have reduce

Provide comfort measures by AM care, changing the linen and touch therapy

For proper hygiene of the patient

Provide safety by placing pillows at the side of the bed Encourage adequate periods of rest and sleep

To avoid patient from presence of injury haematoma

Patient may manifested by: fluid deficit infection acute pain change in turgor edema

To limit metabolic demands, maximize energy and meet comfort needs

VS monitor and

To have baseline

and blood test may cause haematoma.which leads to impaired tissue integrity.

change Identify underlying condition involves in tissue injury

data Suggest treatment options, desire/ability to protect self and potential to recurrence of tissue damage

Assess skin/tissues, bony prominences, pressure areas and wounds Inspect lesions/wounds daily, or as appropriate, for change Monitor laboratory studies

To comparative baseline

Promote timely interventions/revision of plan of care

To changes indicative of healing or infection complications

Help client and family to identify effective successful coping mechanisms and to implement them Discuss importance of early detection and reporting of changes in condition or any unusual physical discomforts Emphasize need to adequate nutritional/fluid intake Provide warm compress

To reduce discomfort and improve quality of life

Promotes early interventions/ reduces potential complications

Optimize healing potential

To improve circulation