ACTUAL NURSING CARE PLAN Dengue Hemorrhagic Fever CUES AND
NURSING
EVIDENCES
DIAGNOSIS
SUBJECTIVE: “Natatakotakos asakitko” as verbalized by the patient. OBJECTIVE:
Poor eye contact Restlessness Increased weariness Voice quivering Facial flushing Increased pulse rate Decreased blood pressure
VS: T- 38 °C P- 102 bpm R- 26 cpm BP- 90/60 mmHg
Anxiety Related to Change in Health Status DEFINITION: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension cause by anticipation of danger. It is an altering signal that warns of impending danger and enables the individual to take measures.
OBJECTIVES
At the end of my shift, the patient will be able to: 1.
Appear relax and report anxiety is reduced to a manageable level.
2.
Verbalize awareness of feeling of anxiety.
3.
Identify healthy ways to deal with and express anxiety.
INTERVENTIONS
INDEPENDENT:
Monitor vital signs
Observe behavior
4.
Demonstrate problem solving skills.
5. Use resources/ supportsystems effectively.
RATIONALE
Determine current prescribed medications and recent drug history of current prescribed or over-the-counter medications Review coping skills used in the past
Be aware of defense mechanism being used
To identify physical responses associated with both medical and emotional conditions To which can point the clients level of anxiety (mild, moderate, severe, panic) These medications can heighten feelings and sense of anxiety
To determine those that might be helpful in current circumstances To identify if there is interference that deals with the clients ability
EVALUATION
1. Goal met as evidenced by appearance of relaxation and report of anxiety is reduced to a manageable level. 2. Goal met as evidenced by verbalized awareness of feelings of anxiety.
3. Goal partially met as evidenced by identified healthy ways to deal with an expressed anxiety. 4. Goal partially met as evidenced by demonstrated some problem solving skills.
REFERENCE: Nurses Pocket Guide 12 th edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr
Provide accurate information about the situation Accept client as is
Helps client to identify what is based The client may need to be where she at this point in time, such as in denial after receiving the diagnosis of a terminal illness
5. Goal partially met. Used resources/sup port systems effectively.
ACTUAL NURSING CARE PLAN Dengue Hemorrhagic Fever CUES AND
NURSING
EVIDENCES
DIAGNOSIS
SUBJECTIVE: “Hindi akomakatulog ngmaayos” as verbalized by the patient. OBJECTIVE:
Restlessness Irritability
VS: T- 39.2 °C P- 97 bpm R- 23 cpm BP- 90/60 mmHg
Impaired Comfort related to be developed DEFINITION: Perceived lack of ease, relief and transcendence in physical, psychospiritual, environmental and social dimensions. REFERENCE: Nurses Pocket Guide 12 th edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr
OBJECTIVES
At the end of my five hour shift, the patient will be able to: 1.
Engage in behaviors or lifestyle changes to increase level of ease.
2.
Verbalize sense of comfort or contentment.
3.
Participate in desirable and realistic healthseeking behaviors.
INTERVENTIONS
RATIONALE
INDEPENDENT:
Determine locus of control Determine the type of discomfort client is experiencing such as physical pain, feeling of discontent, lack of ease in social settings or inability to rise one’s problems or pain Discuss concerns with client and active listen to identify underlying issues
Determine how client is managing pain and pain components
Presence of external locus of control may hamper efforts to achieve sense of piece or contentment
Helps to determine client’s specific needs, ability to change own situation Lack of control may be related to issues, or emotions such as fear, loneliness, anxiety, noxious, stimuli, anger
EVALUATION
1.
Goal met as evidenced by engaged in behavior or lifestyle changes to increase level of ease.
2.
Goal met as evidenced by verbalized sense of comfort or contentment.
3.
Goal met as evidenced by participation in desirable and realistic healthseeking behaviors.
Review knowledge base and note coping skills that had been used previously to change behavior/promote well-being Establish realistic activity goals with client
Review medications or treatment regimen
Provide age appropriate comfort measures
Brings these to client’s awareness and promotes use in current situation
Enhances commitment promoting optimal outcomes To determine possible changes or options to reduce side effects To provide nonpharmacologic pain management
COLABORATIVE:
Collaborate in treating or managing medical conditions involving oxygenation elimination, mobility, cognitive abilities, electrolyte balance, thermoregulation, hydration
To promote physical stability
ACTUAL NURSING CARE PLAN Dengue Hemorrhagic Fever CUES AND
NURSING
EVIDENCES
DIAGNOSIS
SUBJECTIVE: “Nilalagnatako” as verbalized by the patient. OBJECTIVE:
Increase body temperature above normal range. Flushed skin; warm to touch Tachycardia Seizures
Hyperthermia related to illness DEFINITION: Body temperature elevated above normal range. REFERENCE: Nurses Pocket Guide 12 th edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr
OBJECTIVES
At the end of my five hour shift, the patient will be able to: 1.
2.
T- 40.2 °C P- 113 bpm R- 40 cpm BP- 90/50 mmHg
3.
4.
maintain core temperature within normal range Identify underlying cause or contributing factors and importance of treatment, as well as sign and symptoms requiring further evaluative or intervention. Demonstrate behaviors to monitor and promote normothermia
Be free of seizures activity
INTERVENTIONS
RATIONALE
INDEPENDENT:
Assess underlying cause Monitor vital signs Monitor respirations
Monitor and record all sources of fluid loss such as urine vomiting and diarrhea; wounds, fistulas; and insensible losses Maintain bed rest
Monitor ventilation may initially be present, but ventilatoryeffo rt may eventually be impaired by seizures, hyper metabolic state. To reduce metabolic demands and consumption
To support circulating volume and tissue perfusion
EVALUATION
1.
Goal met as evidenced by maintained core temperature within normal range.
2.
Goal met as evidenced byidentified underlying cause or contributing factors and importance of treatment, as well as sign and symptoms requiring further evaluative or intervention.
3.
Goal met as evidenced by demonstrated behaviors to monitor and promote normothermia .
Administer replacement fluids and electrolytes Discuss importance of adequate fluid intake.
DEPENDENT:
Administer medications as ordered
4.
To prevent dehydration To control shivering
Goal met as evidenced by free of seizure activity.
ACTUAL NURSING CARE PLAN Dengue Hemorrhagic Fever CUES AND
NURSING
EVIDENCES
DIAGNOSIS
SUBJECTIVE: “Bumabalik at nawawalaangla gnatko” as verbalized by the patient. OBJECTIVE:
Fluctuate in body temperature above and below normal range Tachycardia Mild shivering Slow capillary refill
VS: T- 39.2 °C P- 97 bpm R- 23 cpm BP- 90/60 mmHg
OBJECTIVES
Ineffective thermoregulation related to illness
At the end of my five hour shift, the patient will be able to:
DEFINITION: Temperature fluctuation between hypothermia and hyperthermia
1.
2. REFERENCE: Nurses Pocket Guide 12 th edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr
3.
Verbalize understanding of individual factors and appropriate interventions Demonstrate techniques and behavior to correct underlying condition or situation Maintain body temperature within normal range
INTERVENTIONS
RATIONALE
INDEPENDENT:
Identify individual factors or underlying condition Initiate emergent or immediate interventions
prepare client and assist with procedures
DEPENDENT: Administer fluids, electrolytes and medications, as appropriate
EVALUATION
1.
Goal met as evidenced by: Verbalized understanding of individual factors and appropriate interventions
2.
Goal met as evidenced by: Demonstrated techniques and behavior to correct underlying condition or situation
3.
Goal met as evidenced by: Maintained body temperature within normal range.
It influences choice of intervention To restore or maintain body temperature within normal range To treat underlying cause of hypothermia and hyperthermia To restore or maintain body and organ function
ACTUAL NURSING CARE PLAN Dengue Hemorrhagic Fever CUES AND
NURSING
EVIDENCES
DIAGNOSIS
SUBJECTIVE: “nanghihinaako ” as verbalized by the patient. OBJECTIVE:
Poor skin turgor Decrease urine output Decrease blood pressure Elevated hematocrit
VS: T- 39 °C P- 100 bpm R- 30 cpm BP- 90/50 mmHg
Deficient fluid volume related to failure of regulatory mechanism
OBJECTIVES
At the end of my five hour shift, the patient will be able to: 1.
DEFINITION: Decreased intravascular, interstitial, and or intracellular fluid. This refers to dehydration, water loss alone without change in sodium. REFERENCE: Nurses Pocket Guide 12 th edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr
Maintain fluid volume at a functional level as evidenced individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill, resolution of edema
INTERVENTIONS
INDEPENDENT: Assess vital signs, noting low BPsevere hypotension, rapid heartbeat, and thread peripheral pulses Establish 24hour fluid replacement needs and routs to be used Change position frequently
2.
3.
Verbalize understanding of causative factors and purpose of individual therapeutic interventions and medications Demonstrate behaviors to monitor and correct deficit as indicated
RATIONALE
Provide frequent oral and eye care Encourage increase OFI Recommend restriction of caffeine alcohol as indicated
DEPENDENT: Administer medications as ordered
These changes in vital signs are associated with fluid volume loss and or hypovolemia Prevents peaks and valleys in fluid level To reduce pressure on fragile skin and tissue To prevent from injury from dryness For fluid replacement To reduce effects of diuresis
For treatment regimen
EVALUATION
1. Goal met, as evidenced by client’s response to interventions, teaching, and actions, performed 2. Attainment or progress towards desired outcome 3. Modification to plan of care
POTENTIAL NURSING CARE PLAN Dengue Hemorrhagic Fever CUES AND
NURSING
EVIDENCES
DIAGNOSIS
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred; rather, nursing interventions are directed at prevention
Risk for Bleeding related to inherent coagulopathies DEFINITION: At risk for a decrease in blood volume that may compromise health. REFERENCE: Nurses Pocket Guide 12 th edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr
OBJECTIVES
At the end of my five hour shift, the patient will be able to: 1.
2.
Be free of signs of active bleeding Display laboratory results for clotting times and factors within normal range for individual risks and engage in appropriate behaviors of lifestyle changes to prevent or reduce frequency of bleeding episodes
INTERVENTIONS
INDEPENDENT: Monitor vital signs Evaluate client’s medication regimen
RATIONALE
Maintain patency of vascular access
Necessity of regular medical and laboratory follow-up when on anticoagulants, such as Coumadin
Use of medications such as nonsteroidal antiinflammatory drugs etc. predispose client to bleeding For fluid administration or blood replacement as indicated To determine needed dosage change, or client management issues requiring monitoring and/or modification
EVALUATION
1. Goal met as evidenced by being free of signs of active bleeding. 2. Goal met as evidenced by satisfactory laboratory results for clotting times and factors within normal range and engaging in appropriate behaviors of lifestyle changes.
Dietary measures
DEPENDENT: Administer medications as ordered
To promote blood clotting, when indicated, such as food rich in vitamin K
POTENTIAL NURSING CARE PLAN Dengue Hemorrhagic Fever CUES AND
NURSING
EVIDENCES
DIAGNOSIS
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred; rather, nursing interventions are directed at prevention
Hypovolemia risk for shock DEFINITION: At risk for an inadequate blood flow to the body’s tissue which may lead to lifethreatening cellular dysfunction REFERENCE: Nurses Pocket Guide 12 th edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr
OBJECTIVES
At the end of my five hour shift, the patient will be able to: 1.
2.
3.
Display hemodynamic stability as evidence by vital signs within normal range for client; prompt capillary refill; adequate urinary output within normal specific gravity; usual level of mentation. Be afebrile and free of other signs of infection, achieve timely wound healing. Verbalize understanding of disease process, risk factors, and treatment plan.
INTERVENTIONS
INDEPENDENT: Monitor vital signs Monitor intake/output Assess for history or presence of conditions leading to hypovolemic shock
RATIONALE
DEPENDENT: Administer fluids, electrolytes, colloids, blood or blood products as indicated
Teach client purpose, dosage, schedule, precautions, and potential sideeffects of medications given to treat underlying conditions.
These conditions deplete the body’s circulating blood volume and ability to maintain organ perfusion and function To rapidly restore or sustain circulating volume, electrolyte balance, and prevent shock Enhances compliance with drug regimen, reducing individual risk
EVALUATION
1. Goal partially met as evidenced by hemodynamic stability. 2. Goal partially met as evidenced by achieved timely wound healing but has an elevated body temperature. 3. Goal met as evidenced by verbalized understanding of disease process, risk factors, and treatment plan.
Encourage consumption of healthy diet, participation in regular exercise, adequate rest
For healing and immune system support
POTENTIAL NURSING CARE PLAN Dengue Hemorrhagic Fever CUES AND
NURSING
EVIDENCES
DIAGNOSIS
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred; rather, nursing interventions are directed at prevention
Illness risk for powerlessness DEFINITION: At risk for perceived lack of control over a situation and/or one’s ability to significantly affect an outcome REFERENCE: Nurses Pocket Guide 12 th edition by Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr
OBJECTIVES
At the end of my five hour shift, the patient will be able to: 1.
2.
3.
4.
5.
Express sense of control over the present situation and hopefulness about future outcomes. Verbalize positive selfappraisal in current situation. Make choices related to and be involved in care. Identify areas over which individual has control. Acknowledge reality that some areas are beyond individual’s control.
INTERVENTIONS
INDEPENDENT: Assess client’s self-esteem and degree of mastery client has exhibited in life situations Be alert for signs of manipulative behavior and note reactions of client and care givers
RATIONALE
Make time to listen to client’s perception of the situation Encourage questions Provide accurate verbal and written instructions about what is happening and what realistically might happen.
Passive individual may have more difficulty being assertive and standing up for rights Manipulation may be used for management of powerlessness because of fear and distrust Shows concern for client as a person
Reinforces learning and promotes selfplaced review
EVALUATION
1. Goal met as evidenced by expressed sense of control over the present situation and hopefulness about future outcomes. 2. Goal met as evidenced by verbalized positive selfappraisal in current situation. 3. Goal met as evidenced by choices made related to and be involved in care. 4. Goal met as evidenced by identified areas over which individual has control.
5. Goal met as evidenced by client’s acknowledge ment of reality that some areas are beyond individual’s control.
