PLANNING (NURSING CARE PLANS) Problem No.

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

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
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 maintained normal body

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

temperature.

>irritability >Diaphoresis patient may manifest:

Increased PR Increased RR Seizure Muscle rigidity

Long Term: After 4 days of NI, the patient will experience no associated complications such as seizures etc.

>Encourage increase fluid intake >Encourage food rich in Vitamin C >to boost body >provide client safety resistance to infection >to prevent further >maintain bed rest injuries >to replace fluid loss

Long Term: After 4days of NI, the patient will experience no associated complications such as seizures etc.

F or 37.5 OC. 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

>to preserve energy

routines and ADLs

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 extremities Long Term: After 2-3 days of NI, the patient will demonstrate increase tissue perfusion AEB normal Hgb level count >Monitor quality of all pulse >loss of peripheral pulses must be reported or treated immediately >assess for possible causative factors r/t temporarily impaired arterial blood flow >early detection of cause facilitates prompt, effective treatment Objectives Short term: After 3 hours of Nursing Interventions the patient will demonstrate behaviors that will improve thee tissue perfusion. >needed for ongoing comparison Long Term: After 2-3 days of NI, the patient shall have demonstrated increase tissue perfusion AEB normal Hgb level count > Monitor vital signs >Assess the patients condition >to have baseline data Interventions > Establish good working condition with the pt and SO Rationale >to gain patients trust Expected Outcome Short term: After 3 hours of Nursing Interventions the patient shall have demonstrated behaviors that will improve thee tissue perfusion.

>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 S> O> patient manifested the following which put his at risk for injury Nursing Diagnosis Risk for injury r/t abnormal blood profile as evidenced by decrease platelet count. Scientific explanation 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 Long Term: After 1 days of NI, the patient will be free from injury. >Provide safe environment (pad, side rails, prevent falls) > Permits > Minimizes injury to occur Long Term: After 1 days of NI, the the patient will have been free from injury. Objectives Short term: After 4 hours of Nursing Interventions, pt will demonstrate techniques behavior, lifestyle changes to risk factors and protect self. >Assess level of consciousness and cognitive level >assist in determining pt. s ability to protect self and comply with required self protective actions Interventions >Establish rapport Rationale >to gain patients trust Expected Outcome Short term: After 4 hours of Nursing Interventions, pt will have demonstrate techniques behavior, lifestyle changes to risk factors and protect self.

Low platelet count Abnormal blood profile Tissue Hypoxia

Pt may manifest Sensory dysfunction Broken Skin Malnutrition

of blood from the system must be stop before shock and possible 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.

> Observe for each stool color, consistency and amount

detection of bleeding in GI tract > Indicate altered

>Observe for hemorrhagic manifestation, ecchymosis, epistaxis, Petechiae, and bleeding gums

clotting mechanism

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

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

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

baseline data

> To promote relaxation and alleviate .

> 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 Nursing Diagnosis Scientific explanation Objectives Interventions Rationale Expected Outcome

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 may manifested by: >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 patient will improve her bowel pattern VS monitor and change To have baseline data 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

Review medication For impact effect

of change in Encourage balance fiber and bulk habit To improve consistence of the stool and facilitate passage through colon Promote adequate fluid intake, including water and high-fiber fruit juice; also suggest drinking warm fluid To promote soft stool and stimulate bowel activity bowel function

Ascertain frequency, color, consistence, amount of stools Provide as baseline of Educate client/SO about safe and risky practice for managing constipation comparison, promotes recognition of changes Information can Review medical/ surgical history help client to make beneficial choices when needed To identify

condition commonly Review appropriate use of medication. Discuss clients current medication regimen with physician To determine if drugs contributing to constipation can be discontinue or change associated with constipation

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 Assessment S= O= patient manifested by: pallor haematoma on both upper extremities weakness Diagnosis Impaired tissue integrity related to mechanical and chemical factor of IV infusion and blood test; secondary to haematoma as Scientific 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 ST After 4 hrs of nursing interventions patient will demonstrate behavior to reduce the hematoma Provide comfort measures by AM care, changing the linen and touch therapy LT For proper hygiene of the patient Objectives Interventions Provide comfortable environment Rationale To ease patients anxiety and to help the patient recover faster for proper hygiene of the patient Patient shall have demonstrate behavior to reduce hematoma ST Expected Outcome

impaired circulation damage tissue

evidence by collection of blood on the upper extremities.

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

LT After 2 weeks of nursing interventions presence of hematoma will be reduce Encourage adequate periods of rest and sleep To limit metabolic demands, maximize energy and meet comfort needs Provide safety by placing pillows at the side of the bed To avoid patient from injury

Patient shall have reduce presence of haematoma

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

VS monitor and change Identify underlying condition involves in tissue injury

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

Assess skin/tissues, bony prominences, pressure areas and wounds Promote timely Inspect lesions/wounds daily, or as appropriate, for change Monitor laboratory studies To changes indicative of healing or infection complications interventions/revision of plan of care

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