Ineffective Tissue Perfusion

A mosquito which carries the dengue virus is called Aedes aegypti. The said mosquito comes in contact with a person and bites the person. The dengue virus will flow through the blood stream and destroys blood components. Patients with dengue often has decreased WBC, platelet & haemoglobin count. Hemoglobin count is used to measure oxygen carrying capacity of the blood. Hemoglobin carries oxygen. Therefore, if there is decreased haemoglobin, there is also decreased oxygen that reaches the different tissues of the body. Assessment Nursing Objectives Diagnosis Subjective: Ineffective Short Term: tissue perfusion After 4 hours (none) related to of NI, the pt will Objective: decreased HgB demonstrate concentration behaviours to Decreased in the blood improve WBC secondary to circulation. DHF 1 Decreased Long Term: platelet Decreased HgB Decreased capillary refill time Dysrhythmias After 4 days of NI, the pt will demonstrate increased perfusion as appropriate Nursing Interventions Rationale Expected Outcome Establish Rapport To gain pts trust The pt shall have To obtain baseline demonstrated Monitor Vital Signs behaviours data to improve Assess patients circulation condition To assess contributing The pt shall factors Note customary have baseline data For comparison demonstrated increased Determine presence of with current perfusion as findings dysrhythmias appropriate To identify Perform blanch test alterations from normal Check for Homans sign To identify / determine Note presence of adequate bleeding perfusion

Altered LOC Fever Chills Diaphoresis

Elevate HOB Encourage quiet & restful atmosphere

To determine presence of thrombus formation

Instruct to avoid tiring To determine risk of anemia activities Encourage light ambulation Encourage use of relaxation techniques Administer medications To promote circulation To promote comfort & decrease tissue O2 demand To decrease cardiac workload To enhance venous return To decrease tension and anxiety level To treat underlying cause

Hyperthermia
When a person comes in contact with a mosquito, Aedes aegypti, the dengue virus flows through the blood stream. As the compensatory mechanism of the body, it will raise its temperature to allow the immune system to work better and to deteriorate the condition of the invaders thus causing hyperthermia. Assessment Nursing Objectives Diagnosis S> (none) Hyperthermia Short Term: O> > Temp of 39.8 > Flushed skin > Skin warm to touch > Chills The pt. May manifest > Increased RR After 4 hours of NI, pts temperature will decrease from 39.8 to 37. Long Term: After 3 days of NI, the pt will identify underlying factors & importance of treatment as well as s/sx requiring further evaluation or Nursing Interventions Rationale Establish Rapport Monitor Vital Signs Assess neurologic response, note LOC & orientation, reaction to stimuli, papillary reactions & presence of seizures Note presence / absence of sweating Wrap extremities with bath towels Provide TSB q 15 minutes Apply local ice packs Expected Outcome To gain pts trust The pt shall have a To obtain baseline decreased body data temperature from 39.8 To evaluate effects & extent of to 37 hyperthermia The pt shall To monitor heat & have identified fluid loss underlying factors and To minimize importance shivering of To reduce body treatment as well as temperature s/sx To reduce body requiring further temperature in evaluation areas of high or

> Tachycardia > Convulsions > Sweating

intervention

in axilla

blood flow

intervention

Instruct client to have To reduce bed rest metabolic demands / oxygen Instruct client to consumption increase OFI To prevent dehydration Administer replacement fluids To support Administer antipyretics circulating blood volume and tissue Reassess temperature q perfusion 15 minutes To restore normal body temperature To determine effectiveness of interventions done

Nursing Interventions for Dengue Hemorrhagic Fever 1. The increase in body temperature related to the process of dengue virus infection. Goal: The body temperature returned to normal Expected Results: o Vital signs within normal limits, especially temperature (36 C - 37 C) o Mucous membranes moist.

Nursing Intervention: Observation of vital signs every 1 hour Rationale: Determining the continued intervention when changes o Give a warm water compress Rational: Compress will provide induction heat expenditure. o Encourage clients to drink lots of 1500 - 2000 ml Rationale: Changing the body fluid that comes out because of heat and spur spending urine. o Suggest to wear thin clothes and absorb sweat. Rational: To provide a sense of comfort and increase the evaporation heat o Observation on the intake and out put Rational: Detection of body fluid volume deficiency. o Collaboration for the provision of antipyretic Rational: Antipyretics useful for heat reduction. 2. Deficit fluid volume related to the migration of intravascular fluid into extravascular
o

Goal: Nothing happens hypovolemic shock Expected results: Blood pressure: 120/80 mmHg, Pulse: 80-100x/mnt, Strong pulse

Nursing Intervention: o Observation of vital signs every hour or more. Rationale: Knowing the condition of intra-vascular fluid. o Observation of capillary refill Rational: Indications of adequate peripheral circulation. o Observation on the intake and output, record the number, color / concentration of urine. Rational: Decrease in urine output / urine is concentrated with an increased density of suspected dehydration. o Encourage to drink plenty of 1500-2000 mL Rational: To meet the needs of body fluids o Collaboration giving intravenous fluids or plasma or blood. Rationale: Increasing the amount of body fluids to prevent hypovolemic shock. 3. Impaired nutrition: less than body requirements related to the decreased appetite Goal: Nutrition fulfilled Results expected: o Increased appetite o Meal spent

Nursing Intervention:
o o o o o

Assess complaints of nausea, vomiting or decreased appetite Rationale: Determining the next intervention. Give foods that are easy to swallow and easy to digest Rationale: Reduce fatigue and prevent gastrointestinal bleeding. Give small portions of food, but often. Rational: Avoiding nausea and vomiting Avoid foods that stimulate: spicy, sour. Rationale: Prevent the occurrence of distension of the stomach which can stimulate vomiting. Give the client's favorite foods Rationale: Allows for more revenue

Collaboration parenteral fluid administration Rational: Parenteral nutrition is needed if the peroral intake was less.

NURSING DIAGNOSIS: Risk for infection: sepsis

related to: A. release of bacteria into the blood associated with: 1. presence of infected necrotic areas or leakage of infected pseudocysts or abscesses (necrotic areas, pseudocysts, and abscesses can develop as a result of destruction of pancreatic and surrounding tissue by the activated proteolytic enzymes) 2. peritonitis (if it occurs); B. decreased resistance to infection associated with decreased nutritional status C. break in skin integrity associated with frequent venipunctures or presence of invasive lines (e.g. intravenous catheter, hemodynamic monitoring devices). Desired Outcome The client will not experience sepsis as evidenced by: a. b. c. d. e. no further increase in temperature absence of chills and diaphoresis pulse and respiratory rate within normal range for client WBC and differential counts returning to normal negative blood culture results.

Nursing Actions and Selected Purposes/Rationales A. Assess for and report signs and symptoms of sepsis (e.g. increase in temperature, chills, diaphoresis, tachypnea, tachycardia, increase in WBC count above previous levels and/or significant change in differential, positive blood cultures). B. Implement measures to prevent sepsis: 1. perform actions to decrease pancreatic stimulation (see Diagnosis 4, action d.5) in order to reduce destruction of pancreatic and peripancreatic tissue and subsequent development of necrotic areas, pseudocysts, and abscesses

perform actions to prevent and treat peritonitis (see Diagnosis 8, actions B and C in peritonitis complication) prepare client for drainage of an abscess or pseudocyst or surgical resection of necrotic tissue if planned maintain sterile technique during all invasive procedures (e.g. venous and arterial punctures) perform actions to maintain an adequate nutritional status (see Diagnosis 3, action c) perform actions to reduce stress (e.g. reduce pain and nausea; provide a calm, restful environment; explain diagnostic tests and treatment plan) in order to prevent an increase in secretion of cortisol (cortisol interferes with some immune responses) 7. change intravenous line sites, tubing, and solutions according to hospital policy and maintain a closed system for intravenous infusions whenever possible 8. anchor catheters/tubings (e.g. intravenous) securely in order to reduce trauma to the tissues and the risk for introduction of pathogens associated with in-and-out movement of the tubing 9. administer antimicrobials as ordered. C. If signs and symptoms of sepsis occur, assess for and immediately report signs and symptoms of septic shock (e.g. systolic blood pressure less than 90 mm Hg; rapid, weak pulse; restlessness; agitation; confusion; urine output less than 30 ml/hour; cool, pale, mottled, and/or cyanotic extremities; capillary refill time greater than 3 seconds; diminished or absent peripheral pulses).

2. 3. 4. 5. 6.

Nursing Care Plan

Nursing Diagnosis: Infection related to microorganism invasion into the body. Long Term Goals: The patient will have negative cultures following antibiotic therapy; temperature < 100F; HR 60-100 beats/min; and MAP >70 mmHg. Outcome/ Short Term Planning/Interventions Patient-Centered Goals The patient will be free Wash hands before and of infection as after each patient care evidenced by negative activity. cultures. Blood glucose will remain < 150 mg/dL. Obtain blood, sputum, urine and wound cultures upon initial suspicion of onset of sepsis. Use strict aseptic technique when handling invasive lines and equipment. Initiate broad spectrum antibiotics early and change to narrow spectrum when culture To locate and identify the source of infection. Rationale Evaluation

To decrease risk of nosocomial infection or transmission of infection.

*Patients temperature is < 100F; cultures remain negative. *The infection is not transmitted to other patients on the unit. *Positive cultures will emerge within 24-48 hours for identification of offending organism. *The patient remains free of signs or symptoms of line infections; Afebrile. *The patient will have negative cultures after treatment with appropriate

To decrease risk of nosocomial infection.

Broad spectrum antibiotics are intended to work against a wide array of organisms,

results are known.

however, it is most prudent to utilize a narrow spectrum antibiotic for treatment once the specific organism has been identified.

antimicrobial treatment.

Date: Nursing Care Plan Patient Initials: Nursing Diagnosis: Decreased cardiac output related to abnormal inflammation, Long Term Goals: The patient will experience hemodynamic stability as evidenced by thrombosis and fibrinolysis MAP >65mmHg; HR 60-100 beats/min; CVP 8-12. Outcome/ Short Term Planning/Interventions Patient-Centered Goals The patient will exhibit signs of adequate perfusion: * MAP > 65 mmHg *CVP 8-12. *HR 60-100 beats/min. Assess patients HR, BP and hemodynamic parameters every hour and after interventions. Rationale Evaluation

Hemodynamic parameters reveal information about adequacy of fluid volume status and tissue perfusion. Serum lactate levels can be indicative of decreased tissue perfusion (and organ dysfunction).

*HR remains 60-100 beats/min. *MAP > 65 mmHg. *CVP 8-12.

Obtain serum lactate levels.

The patient will exhibit Administer fluid Fluid replacement signs of improvement resuscitation to maintain should occur prior to

*The patient will maintain MAP > 65

in cardiac output: *MAP > 65 mmHg. *HR 60-100 beats/min.

MAP > 65 mmHg and CVP 8-12.

treatment with vasopressors.

mmHg.

Administer vasopressors if necessary to maintain MAP > 65 mmHg.

Norepinephrine or dopamine via a central line are first vasopressors of choice (to increase vascular tone and BP) followed by epinephrine.

MAP > 65 mmHg.

Administer drotrecogin alfa (XIGRIS) therapy for patients at high risk of death.

To reduce mortality; It *The patient has reduces development of capillary refill < 3 microthrombi. seconds. *Skin is warm, dry and pink.

Nursing Care Plan for Dengue Hemorrhagic Fever (DHF)

Assessment Assessment is the initial phase of the nurse to obtain the required data before performing nursing care. assessment in patients with "DHF" can be done with the interview technique, measurement, and physical examination. As for step-stages include: * Identify potential sources and are available to meet patient needs. * Assess the patient's medical history. * Assess the increase in body temperature, signs of hemorrhage, nausea, vomiting, no appetite, heartburn, sore muscles and joints, signs of shock (rapid and weak pulse, hypotension, cold and moist skin, especially on the extremities, cyanosis, agitation, decreased consciousness).

Nursing Diagnosis and Intervention 1. Disorders of body fluid volume is less than body requirements related to increased capillary permeability, bleeding, vomiting and fever. Objective: Disorders of body fluid volume can be solved Result Criteria : * Volume of body fluids back to normal Intervention : * Assess the patient's general condition and the condition * Observation of vital signs (Temperature, Pulse) Observation * signs of dehydration * Observations drip infusion, and the location of the insertion of intravenous needles * Balance fluid (the fluid input and output) * Give the patient and family encourage patients to drink plenty

* Instruct the patient's family to change his clothes soaked in patients sweat.