Nursing Scientific Nursing

Assessment Planning Rationale Evaluation

Diagnosis Explanation Intervention
After 8 hours of
Subjective: Ineffective Typhoid Ileitis & DHF nursing After 8 hours of
‘Inaantok at Tissue intervention, the nursing
nanghihina po Perfusion r/t client will be able intervention, the
ako.’’ As Decreased Viral infection to: client was be
 Encourage patient  To help elevate
verbalized by hemoglobin to take iron hemoglobin and able to:
the patient. concentration  Demonstrate supplements and hematocrit levels
in blood AEB eat foods rich in  To promote  Demonstrat
Decreased CBC & different iron. circulation and
Objective: low platelet count ways to venous drainage. e different
hemoglobin improve  Elevate head of  To avoid increased ways to
• Pallor concentration, blood bed to about 10 oxygen demand. improve
degrees. To help client
• Hemoglobin pallor and Decreased level of oxygenation

blood
understand his
= 63 g/L dizziness, and hemoglobin and and  Discourage health condition. oxygenation
• Hematocrit = muscle hematocrit circulation. strenuous
activities.
and
0.19 L/L weakness. circulation.
• Muscle
weakness on Decreased blood  Verbalize
 To maintain
both oxygenation  Provide health compliance to
understandi
extremeties teaching meds. ng of
• Patient  Verbalize regarding DHF condition
and Typhoid Ilietis  Serve as basis for
shows sign pallor, dizziness, understandin and
any alteration in
of dizziness muscle weakness g of condition  Provide health system functions. importance
and teaching on drugs of
being taken. Enhances venous
importance of  treatment
return.
Ineffective tissue treatment regimen.
perfusion regimen.
 Monitor vital
signs.
 Demonstrat
 Help
 Demonstrate control/alleviate e increased
increased Encourage early symptoms tissue
ambulation when
tissue possible.
perfusion.
 Maintain hydration
perfusion. and help wash away
Collaborative: toxins
 Administer
medications as  Packed RBC’s are
ordered adequate for stable
 Administer and patients with
Reference: regulate IVF as subacute/chronic
http://en.wikipedia.org/ ordered bleeding to increase
wiki/Dengue  Administer packed oxygen carrying
RBC’s capability.
 Monitor lab
studies ( Hb,Hct,  Aids in establishing
RBC count) blood replacement
needs & monitorinf
 Nursing Scientific Nursing
Assessment Planning Rationale Evaluation
Diagnosis Explanation Intervention
After 2 hours of After 2 hours
Subjective: Hyperthermia Typhoid Ileitis & nursing of nursing
‘Nilalagnat po related to DHF interventions, the interventions,
ako’’ As underlying patient will be able the patient
verbalized by disease process to: was be able to:
the patient.  Monitor patient’s  Serves as baseline
Viral infection vital signs. data for future
 manifest comparison.To  manifest
Objective: reduction of reductio
promote
Increse WBC core temperature  Note circulation and n of
• Skin warm to from 39.2 to a chronological and venous drainage. core
touch normal range of developmental  Assess for temperature
Elevated 36.5 C- 37.5 C age of client causative/ from 39.2 to a
• Flushed skin temperature contributing normal range
 Note presence/ factor. of 36.5 C- 37.5
• Dry, cracked absence of C
lips sweating.
 To assess degree
 Initiate tepid of hyperthermia.
sponge bath.
 Facilitates heat
 Promotes surface through
cooling through conduction and
undressing or evaporation.
removing extra
linens.  Facilitates heat
loss by radiation
 Encourage
adequate fluid
intake.
 To promote heat
 Encourage loss and
adequate bed hydration.
rest.
Reference:
http://en.wikipedia.  To reduce
org/wiki/Dengue  Instruct patient metabolic
and SO to report consumption and
signs and oxygen demands.
symptoms of
hyperthermia like  To promote
flushed wellness
skin, increasing
respiratory rate
and body
temperature.