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Cues

Nursing Diagnosis

Scientific Reasoning
Fluid volume deficit occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. One common source of fluid loss is nausea and vomiting, bleeding and excessive urination. In Dengue Fever signs and symptoms that could manifest are vomiting and frequent bleeding from gastrointestinal tract in the form of hematemesis or melena that may lead to fluid loss.

Planning
Short term: At the end of my shift, the patients fluid volume will be restore or maintain. Long term: After the discharge of the patient, the patient will have adequate fluid balance

Intervention
Independent: 1. Note potential sources of fluid loss/intake.  Causative/contributing factors for fluid imbalances. 2. Determine childs normal pattern of elimination.  Provides information for baseline and comparison. 3. Continue monitor the vital signs, mucous membranes, weight, skin turgor, breath sounds, urinary and gastric output.  Indicators of hydration status. Note: Hypotension indicative of developing shock may not be readily observed in pediatric patients until very late in the clinical course. 4. Continue monitoring intake and output (accurately), character, and amount of stools, vomiting and bleeding.  Indicates excessive fluid loss or resultant of dehydration. Accurate records are critical in assessing the patients

Evaluation Standard
-the patients fluid volume loss restores and maintain.

Subjective: Risk for Fluid deficit r/t Nagsusuka siya As active fluid volume verbalized by the loss. (vomiting and patients mother. fever) Objective: Vital Signs: T- 37.8 C P- 83 bpm R- 28 cpm BP- 90/70 -on NPO diet -weak in appearance -dry lips -vomited 1x

Criteria
-the patient has sufficient body fluids.

-The patient lips become moist.

-the patient lips are moist.

fluid balance. 5. Continue assessing vital signs (BP, pulse, temperature).  Vital signs changes such as increased heart rate, decreased blood pressure, and increased temperature indicate hypovolemia. Hypotensive and increased pulse rate can be an indication that patient is dehydrated. Dependent: 1. Administer medication as indicated  Useful in reducing fluid losses. Collaborative: 1. Provide/ assist in giving supplemental fluids as indicated (e.g. parenteral, enteral)  To replenish fluid volume for severe dehydration Reference: Nursing Care Plan, Edition 4 By Doenges

Cues

Nursing Diagnosis
Increased body temperature related to the process of dengue virus infection.

Scientific Reasoning
Dengue Fever is potentially deadly complication that is characterized by high fever. Increased body temperature is an abnormal rise in the temperature of the human body. Normal body temperature is 98.6 O F or 37.5 OC. Fever may not result only from a disturbance of heatregulating mechanism of the body but also through disturbances of the blood, the rate of breathing. Indeed there are oral intake during periods of illness will result to further

Planning

Intervention

Evaluation Standard Criteria


-After my 6 hours of nursing intervention my patients body temperature of 37.8 reduce to 37.5c -the patient lips are moist.

Subjective: Nilalagnat yung anak ko As verbalized by the patients mother. Objective: Vital Signs: T- 37.8 C P- 83 bpm R- 28 cpm BP- 90/70 -weak in appearance -dry lips

After 6 hrs of comprehensive nursing intervention the patient temperature will be reduced from 37.8 to 37.5c.

Independent

1. Monitor patient temperature, note shaking chills.  Temperature of 38.9-41c suggest acute infectious disease process 2. Establish good working -The patient lips condition with the patient. become moist.  to gain patients trust 3. Monitor v/s q 2hours.  to have baseline data 4. Monitor environment temperature limit/add bed linens are indicated  Room temperature/number of blankets should be altered to maintain near normal body temperature 5. Provide tepid sponge baths avoid use of alcohol  To promote heat loss by evaporation 6. Provide cooling blanket  Used to reduce fever usually greater than 39.5-40.c.

-Normal body temperature ranges from 36.5-37.5c.

body weakness impairing the patients ability to perform usual routines and ADLs.

7.  8. 

When brain damage seizures can occur Provide client safety to prevent further injuries Maintain bed rest to preserve energy

Dependent: 1. Administer paracetamol by the physician  Used to reduce fever by its central action on the hypothalamus, however fever may be beneficial in limiting growth of organism Reference: Nursing Care Plan, Edition 4 By Doenges