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Diagnosis: Dengue Hemorrhagic Fever

Nursing Care Plan

Cues Goals and


Nursing Data Analysis Intervention Rationale Evaluation
Objectives
Diagnosis

I: The client Hyperther Immediate Goal: By the Effectivenes


verbalizes: mia cause: end of the 8- s:
“Nanghihina related to Illness hour shift, the 1. Was the
pakiramdam illness client will client able
ko” maintain core to accept
“Mainit din Intermediate temperature the different
po katawan cause: within normal measures
ko.” Cytokines range. on how to
1. Monitor core Cerebral hypertension or reduce body
Objectives: temperature peripheral/postural temperature
O: The client 1. Evaluate and BP. hypotension can occur. ?
looks weak Root cause: effects/degre Hyperventilation may ___Yes
and pale. Infection from e of 2. Assess initially be present but ___No
Has elevated Aedes Aegypti hyperthermia neurological ventilatory effort may be
temperature response, level impaired by seizures, 2. Was the
above Nursing of hypermetabolic state. client able
normal implication: consciousness to restate
range. Although fever and orientation. Oliguria and/or renal measure on
Warm to may be 3. Monitor failure may occur due to the
touch. beneficial for respirations. hypotension, promotion
Flushed skin enhancing host 4. Monitor/record dehydration, shock. of wellness?
defense, other all sources of ___Yes
M: factors such as fluid loss such ___No
T: 38 0C the patient’s as urine,
P: 120 bpm comfort and 2. After vomiting and Appropriatenes
R: 28 physiological nursing diarrhea s:
cycles/min responses must interventions, Heat loss by radiation, Were the
BP: 100/70 be considered the client will Discuss with the client conduction and health
mmHg when fever be able to measures on how to convection. interventions
Hgb: 120 occurs. accept the reduce body appropriate ?
Hct: 0.36 Increased different temperature. __Yes ___
PC: 338 cardiovascular measures on 1. Promote No
and metabolic how to reduce surface cooling Heat loss by evaporation
demands may body by means of and conduction. Efficiency:
be poorly temperature. undressing or Areas of high blood flow. Were the
tolerated by cool nursing
persons with environment actions
minimal and/or fans To prevent dehydration. performed
cardiopulmonar 2. Cool/tepid efficiently?
y reserve, such sponge baths ___ Yes __
as those with or immersion To effectively reduce No
coronary artery 3. Local ice packs body temperature and
disease or especially in treat underlying cause Adequacy:
heart failure. groin and (for infection) Were the
axillae. available
4. Increase fluid resources
intake. adequate?
5. Use of To avoid any accident __Yes
hypothermia that might worsen the __No
blanket condition of the client.
6. Administer
antipyretics as Acceptabilit
ordered and For the client’s health y:
other status awareness. Did the
3. The client prescribed client accept
will be able to medications the nursing
restate such as intervention
measure on antibiotics. s?
the promotion 7. Provide safety To prevent dehydration. __Yes
of wellness. of the client. __No

Indicates need for


1. Review specific prompt intervention.
cause such as
underlying
disease process
or
environmental
factors.
2. Discuss
importance of
adequate fluid
intake
3. Review
signs/symptom
s of
hyperthermia
(flusjed skin,
increase
temperature
and
respiratory/hea
rt rate).