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Assessment Diagnosis Inference Goal Interventions Rationale Evaluation

Risk Factors: Risk for deficient fluid Recognition of Short Term: Independent: Short term:
volume related to dengue viral antigen After 1 hr. of nursing Goal Met.
 Decreased decreased blood on infected monocyte interventions, the  Note possible  These conditions .
platelet count = volume secondary to by cytotoxic T cells client will be able to conditions like may lead to fluid  Increased oral
117,000 altered platelet results in cellular demonstrate fluid loss and deficits. fluid intake.
production. direct destruction and behaviors that reduce limited intake.  Enumerate ways
infection of red bone the risk of decreased to prevent
marrow precursor fluid volume as  Monitor I&O  To ensure bleeding
cells as well as manifested by: accurate picture of
immunological fluid status.
shortened platelet  Increased oral
survival causing fluid intake.  Monitor VS  Water loss can
platelet lyses that  Enumerate ways changes. directly affect the
predisposes the host to prevent (e.g. orthostatic body system. (e.g.
to hemorrhage bleeding. hypotension, h20 blood
therefore increasing tachycardia, fever) volume blood
the risk for deficient
supply to the brain
fluid volume.
= hypotension; an
increase in pulse
with decrease BP
can indicate loss
of circulating
blood volume.)

 Assess the signs  The GI tract is the


and symptoms of most usual source
GI bleeding. of bleeding of its
Check for mucosal fragility
secretions.
Observe color and
consistency of
stools or vomitus.

 Observe for  Sub-acute


presence of disseminated
petichiae, intravascular
ecchymosis, coagulation may
bleeding from one develop
more sites
secondary to
altered clotting
factor.
 Encourage use of
soft toothbrush.  Minimal trauma
Avoid straining in can cause
stool, and forceful mucosal bleeding
nose blowing.

 Monitor lab
studies ( Hb,Hct,  Aids in
RBC count, establishing blood
platelet, PTT, replacement
APTT) needs &
monitoring
effectiveness of
therapy.
 Encourage water
for thirst instead of  Juices or soda are
juices or soda. more
concentrated and
has lesser water
content.
 Promote intake of
high-water content  Adds water in the
foods (e.g. diet without
popsicles, gelatin, overwhelming the
eggnog, client with bulk of
watermelon) drinking water.

Collaborative:

 Provide/ assist in
giving  To replenish fluid
supplemental volume for severe
fluids as indicated dehydration
(e.g. parenteral,
enteral)