Dengue
Dengue
Dengue
1 Hyperthermia Assessment S> O> patient manifested: >Flushed warm skin >Increase Temp. of 38.5 C >irritability >Diaphoresis patient may manifest:
Nursing Diagnosis Hyperthermia related to inappropriate clothing factor as evidenced by decrease in platelet count.
Scientific explanation Dengue Hemorrhagic Fever is potentially deadly complication that is characterized by high fever. Hyperthermia is an abnormal rise in the temperature of the human body. Normal body temperature is 98.6 F or 37.5
O O
Objectives Short term: After 4 hours of Nursing Interventions the patient will be maintaining a normal body temperature.
Interventions >Establish good working condition with the pt and SO. >monitor v/s q 2hours. >provide TSB
Expected Outcome Short term: The patients body temperature shall have a
Long Term: After 4 days of NI, the patient will experience no associated complications such as seizures etc. >Encourage food rich in Vitamin C >to boost body resistance to infection >Encourage increase fluid intake >to replace fluid loss Long Term: After 4days of NI, the patient will experience no associated complications such as seizures
C. Fever may
heat-regulating 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 body weakness impairing the patients ability to perform usual routines and ADLs
etc.
Assessment S> O> patient manifested: >appears pale and weak >flushed palms and soles
Scientific explanation Due to the replication of dengue virus in the body, there could be stimulation of production of kinine causing increase vascular permeability leading to capillary damage. Thus will cause internal bleeding. This was manifested through flushed palms and soles and appearance of brownish purplish rashes on the
Objectives Short term: After 3 hours of Nursing Interventions the patient will demonstrate behaviors that will improve thee tissue perfusion.
Interventions > Establish good working condition with the pt and SO >Assess the patients condition > Monitor vital signs
Expected Outcome Short term: After 3 hours of Nursing Interventions the patient shall
tissue perfusion. Long Term: After 2-3 days of NI, the patient shall have demonstrated increase tissue perfusion AEB normal Hgb level count
Long Term: After 2-3 days of NI, the patient will demonstrate increase tissue perfusion AEB normal Hgb level count >assess for possible causative factors r/t temporarily impaired arterial blood flow >Monitor quality of all pulse
extremities
treated immediately >maintain optimal cardiac output >review lab values and note customary baseline data >to increase cellular oxygen supply >to evaluate the importance of NIs given and provide comparison by current findings
Problem # 3: Risk for injury r/t abnormal blood profile as evidenced by decrease platelet count Assessment Nursing Diagnosis Scientific explanation Objectives Interventions Rationale Expected Outcome
S> O> patient manifested the following which put his at risk for injury
Risk for injury r/t abnormal blood profile as evidenced by decrease platelet count.
Risk of Injury as a result of environmental conditions interacting with the individuals adaptive and defensive resources. It is also because of the infection of DHF I Virus that destroys the platelets which place the patient at risk of bleeding. When the blood vessels are cut or damage , the loss of blood from the system must be stop before shock and possible
Short term: After 4 hours of Nursing Interventions, pt will demonstrate techniques behavior, lifestyle changes to risk factors and protect self. Long Term: After 1 days of NI, the patient will be free from injury.
>Establish rapport
Short term: After 4 hours of Nursing Interventions, pt will have demonstrate techniques behavior, lifestyle changes to risk factors and protect self. Long Term:
>assist in determining pt. s ability to protect self and comply with required self protective actions
Pt may manifest
>Provide safe environment (pad, side rails, prevent falls) > Observe for each stool color, consistency and amount >Observe for
After 1 days of NI, the the patient will have been free from
injury.
death may occur. This is accompanied by solidification of the blood, a process called coagulation or clotting. If the value should stop below normal, (150,000 -450,000 g/dl), there is a danger of uncontrolled bleeding because of the essential role that platelets have in blood clotting.
> Promotes healing and boost the resistance of the body against infection
> Assess pts condition and monitor vital signs. > Provide comfort measures, such as stretching bed
linens.
Problem # 4: Risk for constipation related to irregular defecation habits as evidence by defecate once or twice per week Assessment S= Risk for O= patient manifested by: irregular defecation habits inadequate toileting recent environmental changes >change in usual eating pattern >ignoring urge to defecate After 2 hrs of nursing interventions patient will Patient may manifested by: improve her bowel pattern Provide safety by placing pillows at the side of the bed To avoid patient from injury LT: constipation related to irregular defecation habits as evidence by defecate once or twice per week Irregular defecation habits of one or two times per week may cause the stool to harden and dry. It may also cause infection which may lead to constipation After 3 hrs of nursing interventions patient will demonstrate behaviors changes to developing problem Provide comfort measures by AM care, changing the linen and touch therapy For proper hygiene of the patient Patient shall have improve her bowel pattern LT ST Provide comfortable environment To ease patients anxiety and to help the patient recover faster for proper hygiene of the patient Patient shall have demonstrate behavior changes to developing problem ST Nursing Diagnosis Scientific explanation Objectives Interventions Rationale Expected Outcome
>dehydration >electrolyte imbalance >decrease motility of gastro intestinal troat >hemorrhoids Insufficient physical activity Auscultate abdomen for presence, location and characteristics of bowel sounds Reflecting bowel activity VS monitor and change To have baseline data
Review medication
Promote adequate fluid intake, including water and highfiber fruit juice; also suggest drinking warm fluid
Educate client/SO about safe and risky practice for managing constipation
Review appropriate use of medication. Discuss clients current medication regimen with physician
Problem # 5 Impaired tissue integrity related to mechanical and chemical factor of IV infusion and blood test; secondary to haematoma as evidence by collection of blood on the upper extremities. Nursing Scientific Expected
Assessment S= O= patient manifested by: pallor haematoma on both upper extremities weakness impaired circulation damage tissue
Diagnosis Impaired tissue integrity related to mechanical and chemical factor of IV infusion and blood test; secondary to haematoma as evidence by collection of blood on the upper extremities.
Explanation Hematoma is a localized collection of blood, usually clotted, in a tissue or organ. Hematomas can occur almost anywhere on the body. In minor injuries, the blood is absorbed unless infection develops. One of the signs of haematoma is collection of blood in the peripheral area it may be seen in the upper extremities. Mechanical and chemical factors like IV infusion
Objectives ST After 4 hrs of nursing interventions patient will demonstrate behavior to reduce the hematoma LT After 2 weeks of nursing interventions presence of hematoma will be reduce
Rationale To ease patients anxiety and to help the patient recover faster for proper hygiene of the patient ST
Outcome
Patient shall have demonstrate behavior to reduce hematoma LT Patient shall have reduce
Provide comfort measures by AM care, changing the linen and touch therapy
Provide safety by placing pillows at the side of the bed Encourage adequate periods of rest and sleep
Patient may manifested by: fluid deficit infection acute pain change in turgor edema
VS monitor and
To have baseline
and blood test may cause haematoma.which leads to impaired tissue integrity.
data Suggest treatment options, desire/ability to protect self and potential to recurrence of tissue damage
Assess skin/tissues, bony prominences, pressure areas and wounds Inspect lesions/wounds daily, or as appropriate, for change Monitor laboratory studies
To comparative baseline
Help client and family to identify effective successful coping mechanisms and to implement them Discuss importance of early detection and reporting of changes in condition or any unusual physical discomforts Emphasize need to adequate nutritional/fluid intake Provide warm compress
To improve circulation