PROBLEM IDENTIFICATION CUES

Subjective: -The clients wife stated, "Pabalik balik yung lagnat niya, minsan nawawala, pero nagkakalagnat nanaman tapos masakit din yung ulo niya ngayon."

NURSING DIAGNOSIS
Hyperthermia r/t dengue fever as manifested by increased in body temperature above normal range

Mga tatlong araw na siya nilalagnat, bumababa kapag umiinom siya ng gamot tapos tataas nanaman mamaya "Nilalagnat siya kaya namin siya ipinunta sa ospital." verbalized by the client's wife.

Objective: - Temperature = 38.2 - Flushed skin - Warm to touch - Body weakness - Diaphoresis

Subjective: - "Grabe, nagkalat nga yung rashes niya sa buong katawan niya eh tapos sinusuway ko nga siya kasi parati niyang kinakamot." verbalized by the clients wife. - "sobrang kati nga daw kaya di niya mapaigilan kamutin", added by the clients wife. Objective: - Reddened skin rashes in upper and lower extremities

Impaired skin integrity r/t illness as manifested by presence of rashes in the upper and lower extremities

Subjective: As the clients wife stated, - "Ilang beses na din siya nasuka, mga
tatlo na yata."

Risk for deficient fluid volume r/t vomitting

"Minsan wala siya masyadong gana sa pagkain, kasi pag pinilit niya, nasusuka lang siya

PROBLEM PRIORITIZATION CUES

Subjective: -The clients wife stated, "Pabalik balik yung lagnat niya, minsan nawawala, pero nagkakalagnat nanaman tapos masakit din yung ulo niya ngayon."

NURSING DIAGNOSIS
Hyperthermia r/t dengue fever as manifested by increased in body temperature above normal range

RANK

JUSTIFICATION
Hyperthermia has the highest priority because it increases the temperature of the body beyond normal range in response to the disease experienced by the body. This problem requires immediate attention because prolonged elevated body temperature may lead to further hazardous complications, such as dehydration, seizures, and convulsions.

Mga tatlong araw na siya nilalagnat, bumababa kapag umiinom siya ng gamot tapos tataas nanaman mamaya "Nilalagnat siya kaya namin siya ipinunta sa ospital." verbalized by the client's wife.

Objective: - Temperature = 38.2 - Flushed skin - Warm to touch - Body weakness - Diaphoresis

Subjective: - "Grabe, nagkalat nga yung rashes niya sa buong katawan niya eh tapos sinusuway ko nga siya kasi parati niyang kinakamot." verbalized by the clients wife. - "sobrang kati nga daw kaya di niya mapaigilan kamutin", added by the clients wife. Objective: - Reddened skin rashes in upper and lower extremities Subjective: As the clients wife stated, - "Ilang beses na din siya nasuka, mga tatlo na yata." - "Minsan wala siya masyadong gana sa pagkain, kasi pag pinilit niya, nasusuka lang siya

Impaired skin integrity r/t illness as manifested by presence of rashes in the upper and lower extremities

This has the medium priority because the skin is the barrier to infectious agents. However, any break in the skin can readily serve as a portal of entry putting the individual at risk for potential infections. It does not require immediate attention compared to the fever that the client is experiencing.

Risk for deficient fluid volume r/t vomitting 3

Risk for deficient fluid volume has the lowest priority because this is just a risk diagnosis. It is not evidenced by signs and symptoms as the problem has not occured yet. Interventions should be directed at prevention.