NURSING CARE PLAN

Assessment Nursing Diagnosis Scientific Explanation Nursing Goal Nursing Intervention Rationale EvaluationSubjective: “Hindi po siya

makatulog ng maayos.” As verbalized by the father.

Objective: weak with 3-5 hours of

sleep with dark circles

under eyes frequent yawning

Sleeping pattern disturbance related to change in environment.

Illness↓

Hospitalization↓

Noisy Environment↓

Sleep Depriavation

Short Term Goal: After 1-2 hours of

rendering nursing care the patient will:

a) verbalize understanding of sleep disturbance

b) identify individually appropriate interventions to promote sleep

Long Term Goal: Within 2-3 days of

rendering nursing care, the pt will

a) improvement in sleep/rest pattern

b) report increased sense of well-being and feeling rested

Observe and obtain feedback from patient/SOs regarding usual bedtime, rituals/routines, number of hours of sleep, time of arising, and environmental needs.

Determine patient’s/SO’s expectations of adequate sleep.

Identify circumstances that interrupt sleep and frequency.

Discuss or implement effective age appropriate bedtime rituals like

- going to bed at the same time each night

- drinking warm milk- favorite blanket, pillow or

toy

Encourage participation in regular exercise program during day

Recommend inclusion of bedtime snack

- Mild juice- Crackers]- Protein source such as

cheese/peanut butter

To determine usual pattern and provide comparative baseline

To provide opportunity to address misconceptions or unrealistic expectations.

To enhance pt’s ability to sleep

To enhance pt’s ability to fall asleep, reinforce that bed is a place to sleep, and promote sense of security for child.

To aid in stress control/release of energy. Exercise at bed time may stimulate rather than relax patient and actually interfere with sleep.

To reduce sleep inteference from hunger or hypoglycemia

Goal is met. “Mayat mit ti turog

na.” As verbalized by the mother of the patient.

“makaturog akon.” As verbalized by the patient.

With 8-10 hrs of sleep.

Alive in communicating

At ease Absence of dark

circles under eyes Absence of

yawning during the day

Provide for a child’s sleep time safety

- Bed in low position- Non-plastic sheet

Recommend midmorning nap if one is required.

To promote more time in sleeping at night

Napping especially in the afternoon, can disrupt normal sleep pattern.

NURSING CARE PLAN

Assessment Nursing Diagnosis Scientific Explanation

Nursing Goal Nursing Intervention Rationale Evaluation

Subjective: “Ang init nya” as

verbalized by the father of the patient.

“Sumasakit nga rin po ang ulo ko” as verbalized by the pt.

Objective: with flushed skin;

warm to touch Temp = 38.9oC

Hyperthermia related to increased metabolic rate secondary to dengue fever as evidenced by flushed skin; warm to touch and temp of 38.9oC

Chemostatic response

↓Release of chemical

mediators(pyrogen)

↓Stimulation of

thermoregulation in hypothalamus

↓Increase body temperature

↓FEVER

Short Term Goal: After 3-5 hours of

rendering nursing care the pt/SOs will demonstrate behaviors to monitor and promote normothermia.

Long Term Goal: Within 2-3 days of

rendering nursing care, the pt will maintain core temperature within normal range of 36.5oC to 37.5oC.

Monitor core temperature

Provide TSB

Note presence or absence of sweating as body attempts to increase heat loss evaporation, conduction, and diffusion.

Promote surface cooling by means of:

- undressing- cool environment or fans- cool/tepid sponge baths or

To monitor pt’s condition

To decrease body temperature.

Evaporation is decreased by environmental factors of high ambient temperature as well as body factors producing loss of ability to sweat or sweat gland dysfunction.

To promote heat loss by means of:

- radiation &

Goal is met. “Wala na siyang

lagnat. Effective yung pagpupunas sa kanya and yung gamot.” As verbalized by the mother of the patient.

Temp = 37.5oC

immersion- local ice packs, especially in

the groin and axillae

Administer medications

Maintain bedrest

Provide high-calorie diet or parental nutrition

Discuss importance of increase fluid intake

conduction- convection- evaporation &

conduction- areas of high

blood flow To decrease body

temperature

To reduce metabolic demands or oxygen consumption

To meet increases metabolic demands

To prevent dehydration

NURSING CARE PLAN

Assessment Nursing Diagnosis Scientific Explanation

Nursing Goal Nursing Intervention Rationale Evaluation

Subjective: “Nanghihina nga

siya. Tignan mo ang tamlay niya bago pa kami dumating dito ganyan na siya.” as verbalized by the Father of the patient.

Objective: With dry skin and

mucous membrane

Temp = 38.2oC diaphoresis

Fluid volume deficit related to failure of regulatory mechanism secondary to fever as evidenced by dry skin and mucous membrane, temp of 39.1oC..

Injured platelets

Activation of kinin system

Increase vascular permeability

Extravasations of fluid

dehydration

Short Term Goal: After 1-2 hours of

rendering nursing care the pt/SOs will:

a) verbalize understanding of causative factors and purpose of individual therapeutic interventions and medications.

b) Demonstrate behaviors to monitor and correct deficits as indicated.

Long Term Goal: Within 2-3 days, the

pt will maintain fluid volume at a functional level as evidenced by stable vital signs, moist mucous membranes and good skin turgor.

Assess vital signs; note strength of peripheral pulse.

Note physical signs of dehydration and determine customary and current weight.

Establish 24-hour fluid replacement needs and routes to be used.

Note patient preferences regarding fluids and foods with high fluid content.

Keep fluids with patient’s reach and encourage frequent intake as appropriate.

Administer IV fluids within pt’s reach and encourage frequent intake as appropriate

Reduce bedding or clothes, provide tepid sponge bath.

To evaluate degree of fluid deficit.

To evaluate degree of fluid deficit.

To prevent peaks/valleys in fluid level.

To correct or replace losses to reverse pathophysiological mechanisms.

For the pt to easily grab the fluid whenever he’s thirsty.

To replace losses and prevent dehydration

To decrease severe fever and elevated metabolic rate.

To promote comfort

Goal is met. “Ah, o sige ilagay

ko na lang itong tubig sa my mesa malapit sa kanya para madali niyang abutin kapag nauuhaw na siya. ” As verbalized by the mother of the patient.

With moist mucous membrane

With good skin turgor

Temp = 37.5oC

Change position frequently.

Discuss factors related to occurrence of dehydration.

Identify actions patient may take to correct deficiencies.

and safety.

To promote wellness.

To promote wellness.

NURSING CARE PLAN

Assessment Nursing Diagnosis Scientific Explanation Planning Nursing Intervention Rationale EvaluationSubjective Cues:-“Masaki ang tiyan ko”AVB the patient.Objective Cues:-abdominal pain4/5-diaphoresis-facial grimace-guarding behavior

Abdominal pain related to inflammation of the liver.

Replication of Dengue Virus

↓Entry of infection to the

liver↓

Dengue Fever↓

Virus Targets Liver Cells↓

Infection produces↓

Hepatomegaly↓

Abdominal Pain

Short Term Goal-After 3 hours of nursing intervention, the patient

will

NURSING CARE PLAN

Assessment Nursing Scientific Planning Nursing Intervention Rationale Evaluation

Diagnosis explanationSubjective:

”Nahihilo ako pag tumatayo ako”AVB

the patient.

Objective:-looks weak and

pale-anorexic

-with presence of bleeding -presence of

rashes on both upper and lower

extremitiesDecrease appetite

-Vital signs:T-39.1oC

Hgb:12.9g/dl

Risk for ineffective peripheral

tissue perfusion related to

interruption of blood

components and reduction of blood flow

due to bleeding

secondary to systemic viral

infection

Entry of pathogens in the

bloodstream↓

Blood will interfere in the

component↓

Platelet adhesion↓

Platelet destruction

↓Decrease platelet

count↓

Thrombocytopenia↓

Bleeding tendencies

↓Decrease Hgb,

↓Risk for infective peripheral tissue

perfusion↓

Body weakness

*Short- term goalAfter 1-2 minutes of

nursing intervention, the significant others will

verbalize understanding of the patient/s condition

and will demonstrate behaviors that can

improve pt’s circulation

After 8 hours of nursing intervention the patient

will:*maintain normal vital

signs>T-37-37.5

*will improve appetite and will consume atleast ½ of the meals served.

*will increase fluid intake and will consume

atleast 500-600 ml of fluids within 8 hours

LONG TERM GOAL:after a 2-3 days the

patient will free from risk of ineffective

peripheral tissue perfusion as evidence by:

*normal urine output

*assessed patient and monitored vital signs

*explain to the significant others about the disease process

*Encouraged to provide quiet environment, restful atmosphere

>switch off unnecessary light

*Positioned patient in a high fowlers

*Keep needed things within reach

*Schedule activities and routines like vital signs taking

*Always assist patient, encourage SO not to live him for

long

*Encourage SO to provide patient foods rich in IRON like

*this will serve as a baseline data

*enhances venous return

*To provide quiet environment that is conducive for rest

and sleep to decrease oxygen

consumption

*To facilitate lung expansion

*To avoid fatigue and increase oxygen

consumption

*To avoid rest disturbance

*To reduce risk of accidents like falls related to dizziness

*To promote synthesis of

Goal met as evidenced by:-Significant

others verbalized understanding of

the patient’s condition and

they demonstrated behaviors that

improved patient’s

circulation.-showed a stable

vital signs of: Temp=37.5oC

*(-) pale and weak*increase appetite

and* Will able to

consume all the meals served

eggs, fruits, meat like liver and vegetables

*Stress the importance of taking foods rich in vitamin C like

citrus, apple, guava, oranges etc.

COLLABORATIVE:*administered Paracetamol for fever as ordered, 250mg/ml 7.5

ml q4hours*on daily CBC

hemoglobin

*Vitamin C enhances Iron

absorption and it boost immune

system