Patient #4: Dengue Fever Patient

Female, 35

DIAGNOSIS ANALYSIS GOAL NURSING RATIONALE EVALUATION

INTERVENTIONS
Elevated body A state in which an The patient will The client was able
temperature individual’s temperature be able to have – perform TSB – TSB will help in to have a normal
is elevated above a normal body for patient lowering down body temperature
O: normal. Hyperthermia temperature and teach the patient’s
– Has red may occur as a result of before the end the SO on temperature.
flushy skin a disease or disorder of the shift how to – Teaching the
– Has hot skin that occurs on a perform it. SO will save
body surface patient’s body time and effort
S: for the nurse
“ kahapon sobrang Infectious agents and gives more
init ko, ilang araw (Pyrogens) comfort for
ng pabalik balik ↓ stimulate – check patient.
kaya nagpadala na Monocytes temperature.
ako ditto sa ↓ release – To determine
hospital.” Pyrogenic cytokines – refer to the changes.
↓ stimulate nurse on
M: Anterior hypothalamus charge and
BP 110/70 ↓ results in then
PR 68 Elevated administer
thermoregulatory set
RR 24 PRN
point
Temp 39.8 medication:
↓ leads to
Increased Heat – Paracetamol
conservation
↓ (Vasoconstriction/
behavior changes)
Increased Heat
production
↓ (involuntary
muscular contractions)
result in
FEVER
Drug Name Dosage Classification Indication Contraindication Side Effects Nursing Responsibilities

Omeprazole 20mg Antisecretory Short-term Contraindicated with – CNS: Headache, – Administer before meals. Caution
tab OD agent treatment of hypersensitivity to dizziness, patient to swallow capsules whole
active duodenal omeprazole or its asthenia, vertigo, —not to open, chew, or crush
Proton pump ulcer; First-line components; insomnia, apathy, them.
inhibitor therapy in Use cautiously with anxiety, – Arrange for further evaluation of
treatment of pregnancy, lactation. paresthesias, patient after 8 wk of therapy for
heartburn or dream gastroreflux disorders; not
symptoms of abnormalities intended for maintenance therapy.
gastroesophageal – Dermatologic: Symptomatic improvement does
reflux disease Rash, not rule out gastric cancer, which
(GERD); Short- inflammation, did occur in preclinical studies.
term treatment of urticaria, – Administer antacids with
active benign pruritus, omeprazole, if needed.
gastric ulcer; alopecia, dry skin
– GI: Diarrhea,
abdominal pain,
nausea, vomiting,
constipation, dry
mouth, tongue
atrophy
– Respiratory: URI
symptoms,
cough, epistaxis
– Other: Cancer in
preclinical
studies, back
pain, fever

Paracetamol 1.2 mL antipyretics, Mild pain Hypersensitivity to Hema: hemolytic BEFORE:

q 4 hr nonopioid Fever acetaminophen or anemia, ~ Advise parents or caregivers to
PRN analgesics phenacetin; use with neutropenia, check concentrations of liquid
od alcohol. leukopenia, preparations. Errors have
pancytopenia. resulted in serious liver
Hepa: jaundice damage.
Metabolic: ~ Assess fever; note presence of
hypoG associated signs (diaphoresis,
GI: HEPATIC tachycardia, and malaise).
FAILURE, DURING:
HEPATOTO ~ Adults should not take