Assessment
Assessment Diagnosis Diagnosis Planning Planning Inference Inference Implementation Implementation Rationale Rationale EvaluationEvaluation
SubjectiveSubjective
“Ang init init ng “Ang init init ng kapatid ko kapatid ko kapag kapag hinahawakan” hinahawakan” As verbalized As verbalized by the pa by the patient’stient’s
sister. sister. ObjectiveObjective -- V/S taken asV/S taken as follows follows T- 38 degree T- 38 degree celcius celcius PR- 88 bpm PR- 88 bpm RR-22 cpm RR-22 cpm BP-110/70 BP-110/70 mmHg mmHg
-- Flushed skinFlushed skin -- Warm toWarm to touch touch Hyperthermia Hyperthermia related to related to inappropriate inappropriate clothing clothing factor as factor as evidenced evidenced by decrease by decrease in platelet in platelet count secondary count secondary to dengue to dengue hemorrhagic hemorrhagic fever. fever. After 2 hours After 2 hours of nursing of nursing intervention intervention client will be client will be able to able to maintain core maintain core temperature temperature within normal within normal range as range as evidenced by: evidenced by: - body - body temperature is temperature is lowered to 37 lowered to 37 degree celcius. degree celcius. Body temperature Body temperature elevated above elevated above normal level that is normal level that is usually caused by usually caused by several factors several factors related to illness. related to illness. As inoculation As inoculation occurs, proliferation occurs, proliferation of virus follows and of virus follows and once the virus starts once the virus starts to grow in number, to grow in number, it will soon reach it will soon reach it pathogenic level it pathogenic level that will result that will result into pyrexia or into pyrexia or fever as a defense fever as a defense mechanism of the mechanism of the body. body. Reference: Reference: Nurse’s Nurse’s pocket guide by pocket guide by Marilyn Marilyn Doeges10th edition Doeges10th edition Independent: Independent: - Provide tepid - Provide tepid sponge bath sponge bath -Promote surface -Promote surface cooling by means cooling by means of undressing of undressing - Provide cool - Provide cool environment environment -Maintain bed -Maintain bed rest or minimize rest or minimize movement movement - Discuss - Discuss importance importance of adequate fluid of adequate fluid intake particularly intake particularly to the parents. to the parents. -- Strictly monitorStrictly monitor
temperature temperature -Heat loss by -Heat loss by means means of evaporation of evaporation and conduction. and conduction. -Heat loss by -Heat loss by means means of radiation and of radiation and conduction conduction -Heat loss by -Heat loss by means means of convection of convection - To reduce - To reduce metabolic metabolic demands of demands of oxygen oxygen consumption consumption - To prevent - To prevent dehydration dehydration
-- To know if theTo know if the patient’s patient’s temperature temperature went down to went down to
After 4 hours of After 4 hours of nursing nursing intervention intervention goals and goals and objectives was objectives was met as met as evidenced by: evidenced by: - B o d y - B o d y t e m p e r a t u r e t e m p e r a t u r e lowered to 37 lowered to 37 degree celcius. degree celcius.
-Increase fluid -Increase fluid intake intake Dependent: Dependent: Administer Administer paracetamol as paracetamol as prescribed by the prescribed by the physician. physician. Collaborative: Collaborative: Refer to the Refer to the physician if the physician if the temperature still temperature still higher to normal higher to normal range. range. value. value. -- To lower theTo lower the
temparature temparature
-- To alleviateTo alleviate the fever of the the fever of the patient. patient. -- To monitorTo monitor patient’s patient’s condition. condition.
Assessment
Assessment Diagnosis Diagnosis Planning Planning Inference Inference Implementation Implementation Rationale Rationale EvaluationEvaluation
SubjectiveSubjective “Dumudugo “Dumudugo yung labi ng yung labi ng kapatid ko” kapatid ko” As As verbalized verbalized by the by the patient’s patient’s sister sister ObjectiveObjective -Weakness and -Weakness and irritability irritability -Restlessness -Restlessness -V/S taken as -V/S taken as follows: follows: T- 38.1 T- 38.1 PR- 90 bpm PR- 90 bpm R- 22 cpm R- 22 cpm BP- 110/70 BP- 110/70 mmHg mmHg Risk for Risk for hemorrhage hemorrhage related to related to altered clotting altered clotting factor. factor.
-After 3 hours of nursing -After 3 hours of nursing interventions, the client interventions, the client will be able to
will be able to
demonstrate behaviors demonstrate behaviors that reduce the risk of that reduce the risk of bleeding bleeding Most dengue Most dengue infections infections result in result in relatively relatively mild illness, mild illness, but some can but some can progress to progress to dengue dengue hemorrhagic hemorrhagic fever. With fever. With dengue dengue hemorrhagic hemorrhagic fever, the fever, the blood vessels blood vessels start to leak start to leak and cause and cause bleeding from bleeding from the nose, the nose, mouth, and mouth, and gums. gums. Bruising can Bruising can be a sign of be a sign of bleeding bleeding inside the inside the body. body. Without Without prompt prompt treatment, the treatment, the blood vessels blood vessels can collapse, can collapse, causing shock causing shock
-Assess the signs and -Assess the signs and symptoms of symptoms of GI bleeding. GI bleeding. -Check -Check for secretions. for secretions.
-Observe color and -Observe color and consistency of stools consistency of stools or vomitus. or vomitus. -Observe for -Observe for presence of petichiae, presence of petichiae, ecchymosis, bleeding ecchymosis, bleeding from one more sites. from one more sites.
-Monitor pulse, BP -Monitor pulse, BP -Note changes in -Note changes in level level of consciousness. of consciousness. -Encourage use of -Encourage use of so
soft toothbruft toothbrush.sh. Avoid straining in Avoid straining in stool, and forceful stool, and forceful
-The GI tract is the -The GI tract is the most usual source most usual source of bleeding of its of bleeding of its mucosal fragility mucosal fragility -Sub-acute -Sub-acute disseminate disseminate dintra-vascular vascular coagulation may coagulation may develop secondary develop secondary to altered clotting to altered clotting factor. factor. -An increase in -An increase in pulse with decrease pulse with decrease BP can indicate BP can indicate loss of circulating loss of circulating blood volume blood volume -Changes may -Changes may indicate cerebral indicate cerebral perfusion problems. perfusion problems. -Minimal trauma -Minimal trauma can cause mucosal can cause mucosal bleeding bleeding -After 3 hours -After 3 hours of of nursinnursingg interventions, the interventions, the client
client’s’ssister is able tosister is able to demonstrate behaviors demonstrate behaviors that reduce the risk that reduce the risk of bleeding. of bleeding.
shock shock syndrome). syndrome).
-Use small needles -Use small needles for injections. for injections. Apply pressure to Apply pressure to veni puncture sites veni puncture sites for longer than usual. for longer than usual. Dependent: Dependent: Don’t administer Don’t administer aspirin. aspirin. Collaborative: Collaborative: Check for platelet Check for platelet count. count. Check for Check for hematocrit. hematocrit. Report to Report to physician if physician if there’s a there’s a continuous continuous bleeding. bleeding. -Minimize damage -Minimize damage to tissues, reduce to tissues, reduce risk for bleeding risk for bleeding and hematoma. and hematoma. - To prevent - To prevent spontaneous spontaneous bleeding. bleeding.
-To know the -To know the patency of the patency of the hematocrit. hematocrit.
Assessment
Assessment Diagnosis Diagnosis Planning Planning Inference Inference Implementation Implementation Rationale Rationale EvaluationEvaluation Subjective:
Subjective: “Sinasabi
“Sinasabi ng kapatid kong kapatid ko masakit daw tapos tinuturo masakit daw tapos tinuturo niya yung tyan
niya yung tyanniya”niya” AsAs verbal
verbal ized ized by by ththee patient
patient’s’s sister.sister. Objective: Objective: Facial grimace Facial grimace Cle
Clenchnching of fing of f istist ss Pain scale of 5 out Pain scale of 5 out of 10. of 10. Vital Signs: Vital Signs: BP-110/70 BP-110/70 PR-88 PR-88 RR-22 RR-22 T-37.6 T-37.6 VAS-5 out of 10 VAS-5 out of 10
Acute pain and Acute pain and discomfort discomfort related to dengue related to dengue hemorrhagic hemorrhagic fever. As fever. As evidence by evidence by VAS of 5 out of VAS of 5 out of 10. 10. Long term: Long term: After 2 hours After 2 hours of nursing of nursing interventions, interventions, th
the client we client w illill be able to: be able to: a. Verbalize a. Verbalize reports that reports that provide relief. provide relief. b. Demonstrate b. Demonstrate use of use of relaxation relaxation skills and skills and diversional diversional activities as activities as indicated for indicated for individual individual situation. situation. Short term: Short term: After 30 After 30 minutes of minutes of nursing nursing intervention the intervention the patient can: patient can: a. Report pain is a. Report pain is relieved/ relieved/ controlled controlled from a pain from a pain scale of 5 to 1 scale of 5 to 1 Pain Pain modulation modulation refers to the refers to the function of function of neural cells to neural cells to inhibit, reduce, inhibit, reduce, or dampen the or dampen the intrinsic intrinsic modulatory modulatory activity of the activity of the central nervous central nervous system, thus system, thus reducing the reducing the painful stimuli. painful stimuli. Perception is Perception is the conscious the conscious awareness, awareness, usually usually localized in localized in certain areas of certain areas of the body. the body. Level of pain Level of pain perception perception depends on depends on factors such as factors such as personal personal experiences, experiences, immediate immediate environment, environment, and and socio-cultural cultural Independent Independent 1. Assess 1. Assess client’ client’ss response to response to pain: pain: -Perform pain -Perform pain assessment assessment each time pain each time pain occurs. occurs. -Accept
-Accept client’client’ss description of description of pain pain -Observe -Observe nonverbal cues nonverbal cues -Monitor vital -Monitor vital signs signs 2. Assist client 2. Assist client to explore to explore methods for methods for alleviation/cont alleviation/cont rol of pain: rol of pain: -Work with -Work with client to client to To rule out To rule out worsening of worsening of underlying underlying condition/ condition/ development development of of complications complications Pain is Pain is subjective and subjective and cannot be felt cannot be felt by others by others Observations Observations may not be may not be congruent with congruent with verbal reports. verbal reports. Usually Usually altered in altered in acute pain acute pain After 2 hours After 2 hours of nursing of nursing interventions, the interventions, the client was able to: client was able to: a. Report that her a. Report that her pain was pain was reliev reliev ed ed frfrom aom a pain scale of 5 to pain scale of 5 to 1 out of 10. 1 out of 10. b. Demonstrate b. Demonstrate duse of duse of relaxation relaxation skills and skills and diversional diversional activities. activities.
-Provide quiet -Provide quiet environment, environment, calm calm activities activities -Provide -Provide comfort comfort measures like measures like change of change of positions. positions. Dependent: Dependent: Administer Administer pain medicines pain medicines – – Nuprin asNuprin as prescribed by prescribed by the physician. the physician. Collaborative: Collaborative: Check results Check results of the platelets of the platelets of the patient if of the patient if it’s
it’s alreadyalready higher than the higher than the previous previous laboratory. laboratory.
