Assessment Subjective Ang init init ng kapatid ko kapag hinahawakan As verbalized by the patients sister.

Objective - V/S taken as follows T- 38 degree celcius PR- 88 bpm RR-22 cpm BP-110/70 mmHg - Flushed skin - Warm to touch

Diagnosis Hyperthermia related to inappropriate clothing factor as evidenced by decrease in platelet count secondary to dengue hemorrhagic fever.

Planning After 2 hours of nursing intervention client will be able to maintain core temperature within normal range as evidenced by: - body temperature is lowered to 37 degree celcius.

Inference Body temperature elevated above normal level that is usually caused by several factors related to illness. As inoculation occurs, proliferation of virus follows and once the virus starts to grow in number, it will soon reach it pathogenic level that will result into pyrexia or fever as a defense mechanism of the body. Reference: Nurses pocket guide by Marilyn Doeges10th edition

Implementation Independent: - Provide tepid sponge bath

Rationale -Heat loss by means of evaporation and conduction. -Heat loss by means of radiation and conduction -Heat loss by means of convection - To reduce metabolic demands of oxygen consumption

-Promote surface cooling by means of undressing

Evaluation After 4 hours of nursing intervention goals and objectives was met as evidenced by: -Body temperature lowered to 37 degree celcius.

- Provide cool environment

-Maintain bed rest or minimize movement

- Discuss - To prevent importance dehydration of adequate fluid intake particularly to the parents. - Strictly monitor temperature - To know if the patients temperature went down to the normal

value. -Increase fluid intake Dependent: Administer paracetamol as prescribed by the physician. Collaborative: Refer to the physician if the temperature still higher to normal range. - To lower the temparature

- To alleviate the fever of the patient.

- To monitor patients condition.

Assessment Subjective Dumudugo yung labi ng kapatid ko As verbalized by the patients sister Objective -Weakness and irritability -Restlessness -V/S taken as follows: T- 38.1 PR- 90 bpm R- 22 cpm BP- 110/70 mmHg

Diagnosis Risk for hemorrhage related to altered clotting factor.

Planning -After 3 hours of nursing interventions, the client will be able to demonstrate behaviors that reduce the risk of bleeding

Inference Most dengue infections result in relatively mild illness, but some can progress to dengue hemorrhagic fever. With dengue hemorrhagic fever, the blood vessels start to leak and cause bleeding from the nose, mouth, and gums. Bruising can be a sign of bleeding inside the body. Without prompt treatment, the blood vessels can collapse, causing shock (dengue

Implementation -Assess the signs and symptoms of GI bleeding. -Check for secretions. -Observe color and consistency of stools or vomitus. -Observe for presence of petichiae, ecchymosis, bleeding from one more sites.

Rationale -The GI tract is the most usual source of bleeding of its mucosal fragility

Evaluation -After 3 hours of nursing interventions, the clients sister is able to demonstrate behaviors that reduce the risk of bleeding.

-Sub-acute disseminate dintravascular coagulation may develop secondary to altered clotting factor. -An increase in pulse with decrease BP can indicate loss of circulating blood volume -Changes may indicate cerebral perfusion problems. -Minimal trauma can cause mucosal bleeding

-Monitor pulse, BP

-Note changes in level of consciousness. -Encourage use of soft toothbrush. Avoid straining in stool, and forceful nose blowing.

shock syndrome).

-Use small needles for injections. Apply pressure to veni puncture sites for longer than usual. Dependent: Dont administer aspirin.

-Minimize damage to tissues, reduce risk for bleeding and hematoma.

- To prevent spontaneous bleeding.

Collaborative: Check for platelet count. Check for hematocrit. Report to physician if theres a continuous bleeding. -To know the patency of the hematocrit.

Assessment Subjective: Sinasabi ng kapatid ko masakit daw tapos tinuturo niya yung tyan niya As verbalized by the patients sister. Objective: Facial grimace Clenching of fists Pain scale of 5 out of 10. Vital Signs: BP-110/70 PR-88 RR-22 T-37.6 VAS-5 out of 10

Diagnosis Acute pain and discomfort related to dengue hemorrhagic fever. As evidence by VAS of 5 out of 10.

Planning Long term: After 2 hours of nursing interventions, the client will be able to: a. Verbalize reports that provide relief. b. Demonstrate use of relaxation skills and diversional activities as indicated for individual situation. Short term: After 30 minutes of nursing intervention the patient can: a. Report pain is relieved/ controlled from a pain scale of 5 to 1 out of 10.

Inference Pain modulation refers to the function of neural cells to inhibit, reduce, or dampen the intrinsic modulatory activity of the central nervous system, thus reducing the painful stimuli. Perception is the conscious awareness, usually localized in certain areas of the body. Level of pain perception depends on factors such as personal experiences, immediate environment, and sociocultural influences.

Implementation Independent 1. Assess clients response to pain:

Rationale To rule out worsening of underlying condition/ development of complications Pain is subjective and cannot be felt by others

-Perform pain assessment each time pain occurs.

Observations -Accept clients may not be description of congruent with pain verbal reports. -Observe nonverbal cues Usually -Monitor vital altered in signs acute pain

Evaluation After 2 hours of nursing interventions, the client was able to: a. Report that her pain was relieved from a pain scale of 5 to 1 out of 10. b. Demonstrate duse of relaxation skills and diversional activities.

2. Assist client to explore methods for alleviation/cont rol of pain: -Work with client to prevent pain.

-Provide quiet environment, calm activities -Provide comfort measures like change of positions. Dependent: Administer pain medicines Nuprin as prescribed by the physician. Collaborative: Check results of the platelets of the patient if its already higher than the previous laboratory.