Date: September 12 2011 Assessment Nursing diagnosis Subjective: Altered body Mainit ang temperature: pakiramdam ko hyperthermia related

to increase Objective: endogenous pyrogens secondary to DHF >warm to touch >flushed skin >teary eyed Vital signs: BP: RR: 25 T: 38.7 PR: 89

Scientific Explanation Infectious agents (pyrogens) Stimulate monocytes Release pyrogenic cytokines Stimulates anterior hypothalamus Results in elevated thermoregulatory set points Leads to increased heat conservation (vasoconstriction/ behavior changes) Increased heat production (involuntary muscular contractions) Results in fever

Planning After 30minutes to 1 hour of nursing interventions the client will be able to maintain temperature within normal range (36.5-37.5)

Intervention Monitor vital signs especially temperature Perform TSB

Rationale For baseline data

For heat loss by conduction and evaporation

Encourage to wear For comfort; light light and loose clothing colored dress attracts less heat than dark colored clothes. Encourage to increase fluid intake Encourage for high vitamin C diet To maintain hydration

Evaluation After 30minutes to 1 hour of nursing intervention the client was able to maintain temperature within normal range (36.537.5), as evidenced by body temperature of 37.2 GOAL MET!

It helps boost immune system; good immune system is necessary to eliminate infections Anti pyretic drug is for management of fever.

Administer Paracetamol 300mg IV as ordered.

DATE: September 12 2011 Assessment Nursing diagnosis Subjective: masakit po itong tiyan ko P/S:6/10 Objective: >weak looking >with facial grimace >with guarding behavior on Right upper quadrant Vital signs: BP: RR: 25 T: 38.7 PR: 89

Scientific Explanation

Planning After 30 mins to 1 hour of nursing interventions the patient s sensation of pain will be relieved.

Intervention Monitor vital signs Provide comfort measures such as therapeutic touch, repositioning, and nurse presence Instruct patient on focus breathing

Rationale For baseline data To promote non pharmachological pain management

Evaluation After 3 min to 1 hour of nursing intervention the patient was report relieved of pain and controlled as evidence by P/S of 2/10

Alteration in comfort: Virus ultimate the targets liver and spleen, Acute pain related to parenchymal cell chemical and where infection mechanical irritation in produces cell death. the GI mucosal lining associated with decrease platelet Hepatosplenomegaly count.

To destruct attention and reduce tension To prevent patient from fatigue Serve as analgesic and antipyretic drug

Goal met!

abdominal pain Encourage adequate rest periods Administer paracetamol 300mg IV as ordered

DATE: September 13, 2011 Assessment Nursing diagnosis Subjective: Actual bleeding related to decrease platelet count secondary to dengue

Scientific Explanation destruction of platelet (thrombocytopnia)

Planning After the shift the patient will be able to be free from injury of active bleeding such as melena, gum bleeding, and nose bleeding

Intervention Monitor Vital Signs Apply Ice packed

Rationale For baseline data For vasodilation

Evaluation After performing the nursing intervention the patient manifested a decrease episodes of bleeding. Goal partially met!

Objective: >Low platelet count: 24 8/1/2011 >body weakness >with petechiael rashes Vital signs: BP: RR: 25 T: 38.7 PR: 89

Decrease coagulation

Advice pt. to use soft bristle toothbrush Advise pt. to lessen picking his nose

To reduce risk for injury to oral mucosa To prevent bleeding associated with tissue injury Scratching the skin with long nails may cause bleeding To monitor if there bleeding in the upper GI

Risk for bleeding

Assisted patient in trimming her nails

Advised pt. to avoid dark colored foods such as chocolate and dark red meat Advised pt. to avoid soft drinks such as coke and pop

Soft drinks may irritate the mucosal lining in the GI that may cause bleeding

DATE: September 13, 2011 Assessment Nursing diagnosis SO- Diaphoresis -epistaxis -Pale looking -with nasal packed at right nares soaked with blood. - Skin Turgor 4 secs. -decrease platelet count: 24, -Decrease Hematocrit 0.31 BP:120/80 Hemorrhagic shock; Hypovolemia realted to excessive vascular fluid loss.

Scientific Explanation Decrease platelet

Planning After 4-8 hours of nursing intervention the patient will be able to maintain fluid volume at functional level as evidenced by: Individually adequate urinary output , stable vital sign, good skin turgor and negative episodes of bleeding.

Intervention Monitor vital sign especially blood pressure. Administer fluids and electrolytes (200cc D5LR as fast drip) Establish 24hrs fluid replacement needs. Provide food and beverages high in fluid content except dark color foods. Encourage increase oral fluid intake. Monitor closely of intake and output. Instruct SO in how to measure and record input and output.

Rationale

Evaluation After performing the nursing intervention the patient established behaviors in increasing his fluid intake manifested by: drinking Gatorade, and fruit juices. Skin turgor back into normal range from 4 seconds to 3 seconds. Goal partially met!

Bleeding tendency

rupture of capillaries (BLEEDING) Further decrease of platelet

INTERNAL BLEEDING

SHOCK

DATE: September 12, 2011 Assessment Nursing diagnosis SO- Diaphoresis -epistaxis -Pale looking -Hemoptesis -with nasal packed soaked with blood -estimated blood loss 200cc/episodes of vomiting. -decrease platelet count 26(7-31-2011) - hematocrit level 0.41 (7-31-2011) Bp:120/80 Risk for injury; hemorrhage related to decrease platelet.

Scientific Explanation Decrease platelet

Planning After 4-6 hours of nursing intervention the patient will be able to demonstrate behaviors, lifestyle changes, to reduce risk factor and protects self from injury.

Intervention Monitor vital sign especially blood pressure. Administer fluids and electrolytes (200cc D5LR as fast drip) Establish 24hrs fluid replacement needs. Provide food and beverages high in fluid content except dark color foods. Encourage increase oral fluid intake. Monitor closely of intake and output. Instruct SO in how to measure and record input and output. Blood transfusion as ordered (2 units platelet concentrate fast drip, fresh whole blood 1 unit x 2hrs

Rationale

Evaluation After performing the nursing intervention the patient modify Environment as indicated to enhanced safety. Goal partially met!

Bleeding tendency

easily ruptured of the capillaries. Risk for injury

Ice chips and nasal ice packed at the nasal bridge and at the gums. Use soft bristled toothbrush.