Patient: Wilhelm Devera
CC: Fever
Nursing Diagnosis
Risk for bleeding, vulnerable to
a decrease in blood volume,
which may compromise health
Subjective:
“Isinugod agad namin siya sa
ospital nung unang araw pa
lang na nagkalagnat siya kasi
umabot na ng 41˚C yung
temperature niya” as
verbalized by the mother.
Objective:
(+) loss of appetite
(+) Abdominal Pain
(+) Platelet count of 10
(+) Moderate Bleeding in the
nose and mouth on 4th day of
illness
(+) Herman’s Rash
VS taken as follows:
T – 36˚C
P – 67 bpm
R – 24
BP – 90/60 mmHg
Age: 15 years old
Admitting Dx: Systemic Viral Infection, Dengue Fever with Warning Signs
Inference
Dengue fever is a benign, acute
febrile syndrome. The virus
causes increased vascular
permeability that leads to
bleeding diathesis. This
infectious disease is manifested
by a sudden onset of fever,
with headache, peri-orbital
pain, rash over the face,
thorax, and flexor surfaces,
body weakness, malaise,
lethargy, and mild hemorrhagic
manifestations.
Plan of Care
After the end of the 2-day
nursing intervention, the
patient will be able to reduce
the risk of bleeding.
Nursing Intervention
Independent:
Assess for signs and symptoms
of GI bleeding. Monitor for
episodes of bleeding from the
nose, mouth, gums, or under
the skin.
Observe for presence of
petechiae and Herman’s rash.
Monitor vital signs, particularly
blood pressure.
Watch out for Narrowing of
Pulse Pressure
Rationale Evaluation
The GI tract (esophagus and Goal met, the patient
rectum) is the most usual manifested no further bleeding
source of bleeding when the on the nose and mouth.
mucosal lining of the GI tract is
inflamed. The patient now has a good
appetite.
Herman’s rash is due to an
increase capillary permeability No more complain of
and fluid leakage as a result of abdominal pain
damaged capillary walls from
an immune complex reaction
secondary due to the infection. Vital signs as follows:
T- 35.5°C
P- 60 bpm
R- 20
Hypotension is an initial BP- 90/60mmHg
compensatory mechanism
usually noted with bleeding. Platelet count increases from
10 to 28.
Increasing heart rate and
narrowing pulse pressure that
can be identified through
taking the blood pressure may
present a state of early shock
(normotensive shock) which is
very common for dengue
patients.
Patient: Wilhelm Devera Age: 15 years old
CC: Fever Admitting Dx: Systemic Viral Infection, Dengue Fever with Warning Signs

Monitor the platelet and CBC When bleeding is not visible,

result (Hct and Hgb) decreased Hgb and Hct levels
may be an early indicator of
bleeding.

Ask the patient’s guardian to Note patient’s report of pain in

report any abdominal pain the abdomen for it is one of
the warning signs of dengue.

Avoid use of NSAIDs The use of NSAIDs does not

only decrease normal platelet
aggregation but also decrease
the integrity of gastric mucosa
and therefore increase the risk
for gastrointestinal bleeding.

Foods which are dark in color

Avoid Highly-Colored Food may interfere with the
observation for upper and
lower GI tract bleeding.

Fresh Frozen Plasma replaces

Administration of FFP clotting factors and inhibitors.

It helps to keep the body

Administer IVF hydrated.
Patient: Wilhelm Devera Age: 15 years old
CC: Fever Admitting Dx: Systemic Viral Infection, Dengue Fever with Warning Signs

 D5 LR This is used for replacing fluids

and electrolytes in those who
have low blood volume.

Give medications as ordered by

the patient’s AP

 Paracetamol 500 mg Relief of fever, minor aches,

and pains.

 Hemostan 500 mg Treatment & prophylaxis of

hemorrhage associated w/
excessive fibrinolysis.

 Alnix 10 mg Symptomatic relief of allergic

conditions including rhinitis &
chronic urticarial.

 Prevacid 30 mg For acute gastric mucosal

lesion accompanied by
bleeding.
Patient: Wilhelm Devera Age: 15 years old
CC: Fever Admitting Dx: Systemic Viral Infection, Dengue Fever with Warning Signs