X.

NURSING CARE PLAN NURSING ASSESSMENT DIAGNOSIS Subjective: Hyperthermia Kahapon pa siya may lagnat as verbalized by the patients mother. related to direct effect of circulating endotoxins on the hypothalamus altering Objective: Increased Body Temp:37.9 Profuse sweating Dry lips and mucous membranes Flushed skin Warm to touch temperature regulation.

RATIONALE Dengue Fever

PLANNING After 8 hours of nursing intervention, the

NURSING INTERVETION Monitor patient temperature (degree and pattern) and note shaking chills or profuse diaphoresis. Monitor environmental temperature; limit or add bed linens as indicated.

RATIONALE Temperature of 38.9 41.1 C suggests acute infectious diseases process. Fever pattern may aid in diagnosis.

EVALUATION Goal is met, after 8 hours of nursing intervention, the patient achieved a temperature

Elevated WBCs

patient will demonstrate a temperature within the

Release of endotoxins, that cause disruption of hypothalamic set point.

normal range, free of chills and associated complications. Provide tepid sponge baths; avoid use of alcohol.

Room temperature or number of blankets should be altered to maintain near normal temperature. May help reduce fever. Use of alcohol may cause chills, actually elevating temperature. Used to reduce fever by its central action on the hypothalamus.

within the normal range as evidenced by a decreased in body temperature from 37.9 C to 36 C Patient was also free of chills and

Administer antipyretics like paracetamol (biogesic). Provide cooling blanket.

associated complications.

Increase in body temperature

Used to reduce fever usually greater than 40C when seizures can occur

ASSESSMENT Subjective: Ayaw kumain ng anak ko as verbalized by the patients mother.

NURSING DIAGNOSIS Imbalanced Nutrition: less than body requirement related to loss of appetite secondary to

RATIONALE Dengue Fever

PLANNING After 3 days of nursing intervention,

NURSING INTERVETION Independent: Assess causative/contributing factor: Assess client's weight, age, strength, activity/rest level, and so forth Assess nutritional history, including food preferences Observe and record patients food intake

RATIONALE

EVALUATION Goal is met, after 3 days of nursing intervention, patient

Joint pain

patient will demonstrate stable weight

Provides comparative baseline

demonstrated stable weight and is free of signs of

Nausea/ Vomiting

and will be free of signs of malnutrition. Patient or Identify deficiencies, suggests possible interventions To monitor caloric intake or insufficient quality of food consumption

Objective: Decreased tolerance for activity Weakness Loss of muscle tone. Weight upon admission in kilograms:28

dengue virus.

malnutrition. Patients mother also verbalized and demonstrated behaviors and lifestyle changes

Anorexia

mother will demonstrate behaviors or lifestyle changes

Decrease appetite

to maintain appropriate weight.

Encourage client to choose food that are appealing to increase appetite Avoid foods that cause intolerance, increase gastric motility that results in epigastric pain blanket.

Children eat a lot of to maintain food that are appealing patients to their taste appropriate Foods such as gasforming, spicy, too hot, too cold, caffeinated beverages can result to epigastric pain that will decrease appetite leading to weight loss weight.