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NURSING CARE PLAN 1 Nursing Diagnosis: Hyperthermia related to increased metabolic rate secondary to presence of dengue fever Subjective:

Balik-balik lage akong hilanat, as verbalized by the patient. Objective: Received patient lying on bed; awake, conscious and coherent, non-dyspneic Febrile with temperature of 38.6oC Decreased appetite noted Skin warm to touch Increased respiratory rate of 32cpm Goals: Within 8 hours of appropriate nursing interventions, the client will be able to: Maintain core temperature within normal range Demonstrate behaviors to monitor and promote normothermia Interventions (with rationale) Promotive: I: Monitor vital signs R: Dysrhythmias are common due to fluid and electrolyte imbalance, dehydration; to assess for continuous temperature changes; S: Doenges, 2006 I: Note absence of sweating as body attempts to increase heat loss by evaporation, conduction and diffusion R: Evaporation is decreased by environmental factors of high humidity and high ambient temperature S: Doenges, 2006

Preventive: I: Monitor and record all source of fluid loss such as urine and vomiting R: Potentiates fluid and electrolyte losses S: Doenges, 2006

Curative: I: Encourage increase of oral fluid intake R: to promote normothermia S: Doenges, 2006

I: Encourage adequate rest and limit activities within clients tolerance R: to limit metabolic demands S: Doenges, 2006 I: Promote calm/ restful environment R: Helps limit oxygen needs S: Doenges, 2009 I: Promote surface cooling by means of tepid sponge bathing and modifying environment R: Promotes heat loss by evaporation and conduction; convection S: Doenges, 2002 I: Administer replacement fluids and electolytes R: to support circulating volume and tissue perfusion S: Doenges, 2002 I: Instruct in the use of relaxation, stress reduction techniques as appropriate R: to limit metabolic demands and to promote comfort S: Doenges, 2009 I: Maintain bed rest R: to reduce metabolic demands S: Doenges, 2002 I: Promote patient safety R: to assist with means to restore normal body function S: Doenges, 2002 I: Monitor vital signs every 2 hours as indicated R: to evaluate effects/degree of hyperthermia S: Doenges, 2002 I: Discuss importance of adequate fluid intake R: to prevent dehydration S: Doenges, 2006 I: Review with client the signs and symptoms of hyperthermia R: Promotes need for immediate intervention, if necessary S: Doenges, 2006 TERTIARY INTERVENTIONS: Rehabilitative: I: Administer medications (antipyretics and etc.) as indicated R: to reduce body temperature and to treat underlying cause S: Doenges, 2006

Theoretical Basis: Plasma leakage, haemoconcentration and abnormalities in homeostasis characterize dengue. The mechanisms leading to severe illness are not well defined but the immune response, the genetic background of the individual and the virus characteristics may all contribute to dengue. A transient and reversible imbalance of inflammatory mediators, cytokines and chemokines occurs during dengue, probably driven by a high early viral burden, and leading to activation of increased thermoregulation to counter the imbalance. Source: World Health Organization. 2009. DENGUE GUIDELINES FOR DIAGNOSIS, TREATMENT, PREVENTION AND CONTROL. New Edition. WHO Library Cataloguing-in-Publication Data

NURSING CARE PLAN 2 Nursing Diagnosis: Risk for fluid volume deficit related to fluid loss Subjective: No verbal cues Objective: Received patient lying on bed; awake, conscious and coherent, non-dyspneic With # 3 PNSS 1L @ 60 gtts/min infusing well on right arm Febrile with temperature of 37.9oC, pulse rate is 80 bpm Dry mouth noted Profuse sweating noted Fatigue noted Stable I and O Good skin turgor Goals: Within 8 hours of appropriate nursing interventions, the client will be able to: Demonstrate behaviors to monitor and correct deficit as indicated Maintain fluid volume at a functional level as evidenced by stable vital signs, stable intake and output ratios and/or moist mucous membranes Interventions (with rationale) Promotive: I: Assess vital signs, noting low BP, rapid heartbeat and thread peripheral pulses R: to evaluate risk for fluid deficit S: Doenges, 2006

Preventive: I: Note complaints and s/sx associated with dehydration R: to evaluate risk for fluid deficit S: Doenges, 2006 I: Establish 24-hour fluid replacement needs and routes to be used R: Prevents peaks/valleys in fluid level S: Doenges, 2006 Curative: I: Keep fluids within clients reach and encourage increase in oral fluid intake, as appropriate R: to maintain hydration

S: Doenges, 2006 I: Monitor intake and output; weigh client daily R: to monitor fluid status S: Doenges, 2006 I: Promote calm/ restful environment R: Helps limit metabolic rate S: Doenges, 2006 I: Administer replacement fluids and electolytes R: to support circulating volume and tissue perfusion S: Doenges, 2006 I: Provide frequent oral care R: to prevent injury from dryness S: Doenges, 2006

TERTIARY INTERVENTIONS: Rehabilitative: I: Administer and regulate IV fluids as indicated R: to promote fluid balance S: Doenges, 2006

Theoretical Basis: Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. Common sources for fluid loss are the gastrointestinal tract, polyuria, and increased perspiration. Fluid volume deficit may be an acute or chronic condition managed in the hospital out patient center, or home setting. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of restoring fluid volume and correcting any electrolyte imbalances. Early recognition and treatment are paramount to prevent a potentially life-threatening hypovolemic shock. Source: Gulanick,M., Myers, J. 2007. Nursing Care Plans: Nursing Diagnosis and Intervention. 6th ed. Mosby Elsevier Publishing.

NURSING CARE PLAN 3 Nursing Diagnosis: Risk for injury related to fatigue as evidenced by decreased hematocrit level Subjective: No verbal cues Objective: Received patient lying on bed; awake, conscious and coherent, non-dyspneic, afebrile Slowed reactions and movements noted Seen patient sitting dangling at bedside Fatigue and weakness noted Unkempt appearance noted Latest hematocrit level = 0.18

Goals: Within 8 hours of appropriate nursing interventions, the client will be able to: Verbalize understanding of individual factors that contribute to possibility of injury Demonstrate behaviors to reduce risk factors and protect self from injury Interventions (with rationale) Promotive: I: Perform thorough assessments regarding safety issues when planning for client care R: Failure to accurately assess and intervene or refer these issues can place the client at further risk S: Doenges, 2008

Preventive: I: Ascertain knowledge of safety needs R: to assess patients knowledge of risk S: Doenges, 2008 I: Assess clients muscle strength, gross and fine motor coordination R: to identify risk for falls S: Doenges, 2008 Curative: I: instruct client to request assistance as needed R: to assist client in reducing risk factors S: Doenges, 2008

I: Advised SO to keep a close watch on client and to assist client in ambulation R: to promote safety S: Doenges, 2008 I: Assist in repositioning and ambulation R: to promote safety S: Doenges, 2008 I: Monitor environment for potentially unsafe conditions and modify as needed R: Environmental aspects can contribute to occurrence of injury S: Doenges, 2008 I: Discuss importance of self-monitoring of condition R: To promote clients independence S: Doenges, 2008

TERTIARY INTERVENTIONS: Rehabilitative: I: Evaluate client and SOs learning R: to assess degree of knowledge gained and to facilitate further health teachings S: Doenges, 2006

Theoretical Basis: Any condition that causes the quantity of oxygen transported to the tissues to decrease ordinarily increases the rate of red blood cell production. Thus, when a person becomes extremely anemic as a result of hemorrhage or any other condition, the bone marrow immediately begins to produce large quantities of red blood cells. At very high altitudes, where the quantity of oxygen in the air is greatly decreased, insufficient oxygen is transported to the tissues, and red cell production is greatly increased. In this case, it is not the concentration of red blood cells in the blood that controls red cell production but the amount of oxygen transported to the tissues in relation to tissue demand for oxygen. Various diseases of the circulation that cause decreased blood flow through the peripheral vessels, and particularly those that cause failure of oxygen absorption by the blood as it passes through the lungs, can also increase the rate of red cell production. This is especially apparent in prolonged cardiac failure and in many lung diseases, because the tissue hypoxia resulting from these conditions increases red cell production, with a resultant increase in hematocrit and usually total blood volume as well. But when the erythropoietin system is functional, hypoxia causes a marked increase in erythropoietin production, and the erythropoietin in turn enhances red blood cell production until the hypoxia is relieved. However, there are conditions that decrease hematocrit levels, implying a decreased oxygen-carrying capacity of the red blood cells. These conditions may predispose a person to fatigue as there is a problem with tissue oxygenation.

Risk for injury is defined as being at a risk for injury as a result of environmental conditions interacting with the individuals biopsychological, adaptive and defensive resources. Source: Doenges, M.,et.al. 2006. Nurses Pocket Guide. 11th ed. FA Davis Company. Guyton, A and Hall, J. 2006. Textbook of Medical Physiology. 11th ed. Elsevier Saunders Inc.