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NDx#2: Risk for dehydration related to less fluid intake

Objective cues:

 Fluid intake: 500 ml from 5 am to 12 pm


 Output: 450 ml from 5 am to 12 pm
 Dry lips
NDx#1: Acute pain related to vomiting  Dry skin
Ndx#3: Risk for bleeding related to
Objective cues:  Yellow orange colored urine
decreased platelets
 (+) facial grimace 0800H 1000H 1200H
Objective cues
T=36.8 T=36.5 T=36.6 (NV:
0800H 1000H 1200H 36.5- 37.5) 0800H 1000H 1200H
T=36.8 T=36.5 T=36.6 (NV: RR=20 RR=20 RR=21 cpm T=36.8 T=36.5 T=36.6 (NV:
cpm cpm (NV: 20-25)
36.5- 37.5) 36.5- 37.5)
PR=80 PR=121 PR=113 (NV: RR=20 RR=20 RR=21 cpm
RR=20 RR=20 RR=21 cpm bpm bpm 65-110 bpm)
cpm cpm (NV: 20-25) cpm cpm (NV: 20-25)
BP= BP= BP= 90/60 PR=80 PR=121 PR=113 (NV:
90/60 90/60 (NV: 90- bpm bpm 65-110 bpm)
PR=80 PR=121 PR=113 (NV: 100/60-70)
BP= BP= BP= 90/60
bpm bpm 65-110 O2= O2= O2= 99% (NV: 90/60 90/60 (NV: 90-
bpm) 98% 97% 95-100%) 100/60-70)
BP= BP= BP= 90/60 Subjective cues: O2= O2= O2= 99% (NV:
90/60 90/60 (NV: 90- 98% 97% 95-100%)
 “Hindi pa po ako dumumi”
100/60-70) Subjective cues:
 Mother verbalized, “pinapainom ko nga ayaw uminom”  Mother verbalized “pwede bang
O2= O2= O2= 99%
98% 97% (NV: 95-  Mother verbalized, “sumuka kasi siya kanina” malaman yung test sa platelets niya?
100%)  “konti lang po iniinom ko” Dapat makakalabas na kami kasi
malakas naman na siya kaso sabi nung
doctor niya hindi pa pwede kasi kahapon
Subjective cues: bumaba daw platelets niya pero nasa
normal parin naman kaso kada araw
 Pain scale: 5/10 Medical diagnosis: Dengue pababa ng pababa platelets niya”
 “ masakit po yung tiyan ko fever with warning signs
kanina”
 Mother verbalized “sumuka kasi Prioritization:
siya kanina”
 Vital signs
 Physical examination
 Input and Output

Patient’s Initials: J.B Medical Diagnosis/ Chief Complaint: Dengue fever with warning signs
Age: 5 years old Basis for Prioritization: Urgency
Gender: Male Date admitted: October 6,2019 Student Nurse/s: Aquino, Navarrete, Parangue, Ramos