NURSING CARE PLAN

Name: Eric Beclasiado

Address: San Antonio, Minalabac Camarines Sur
Room/area: ER- pedia (Bicol Medical Center)

CUES
Subjective:
(none)
Objective:
patient
manifested:
-flushed warm skin
-increase temp. of
38.5C
-Irritability
-diaphoresis
-patient may
manifest:
*increased Pulse
Rate: 90 bpm
*increased
Respiratory Rate:
25cpm
*chills
*muscle spasms
*platelet
count:50,000/mm3

NURSING DIAGNOSIS

Hyperthermia
related to
inappropriate
clotting factor as
evidenced by
decreased
platelet count

RATIONALE
When the person comes
in contact with a
mosquito, aedes aegypti,
the dengue virus flows to
the blood stream. As the
compensatory
mechanism of the body,
it will raise its
temperature to allow the
immune system to work
better and to deteriorate
the condition of the
invaders thus causing
hyperthermia.

Age/sex/civil status: 9 years old; male; child

Diagnosis: Dengue Hemorrhagic fever

PLANNING
Short Term:
After 4 hours of NI,
pts temperature will
decrease from 39.8
to 37.

NURSING
INTERVENTIONS
1. Provide / encourage
patients to drink plenty
of 1500-2000 cc / day
(as tolerated)

RATIONALE

EXPECTED
OUTCOMES

To replace fluids lost due to

evaporation.

Short term:
The patients
2. Instruct the patient to To provide a sense of
body
wear clothing that is thin comfort and easy thin
temperature
Long Term:After 3
clothing that absorbs sweat shall have a
days of NI, the pt will and easy to absorb
sweat
and does not stimulate an
maintained
identify underlying
increase in body
normal body
factors & importance
temperature.
temperature.
of treatment as well
as s/sx requiring
further evaluation or
3. Observations intake Early Detect dehydrated,
Long Term
intervention
and output, vital signs
and knowing fluid and
:After 4days
(temperature, pulse,
electrolyte balance in the
of NI, the patient
blood pressure) every 3 body. Vital Signs is a
will experience
hours once or more
reference to determine the no associated
often.
patient's general condition. complications
such as seizures

4. Collaboration: the

Fluid replacement is
essential for patients with a
high body temperature.

Prepared by: CASTROVERDE, JOANNAH MARIE C.

administration of
Drugs specifically to lower
intravenous fluids and the patient's temperature.
medications as ordered.

Drug Study
Brand name/ Dosage

ISOPRINOSINE
2tsp TID 250mg

Indication

Mechanism of Action

Side Effects

Nursing Management

Monitor increase in serum uric

acid level, gout, urolithiasis or
Rhinovirus; herpes genitalis;
renal dysfunction; pregnancy and
measles; encephalitis; influenza;
Transient increase in urine and lactation>Monitor hematological
Synthetic antiviral: it stimulates Therpes zoster; herpes simplex;
serum uric acid level; very
parameters
lymphocytes; used for HIV and
type A & B hepatitis; AIDS related
rarely skin rashes; pruritus; GI
Hepatitis>non-toxic immune system
complex; neoplastic diseases;
upset; nausea; fatigue;
Patient Teaching:Inform patient
stimulant
anergy and hypoergy prior to major
malaise
that the drug must be taken 1 hour
surgery
apart on an empty
Stomach>Instruct the patient to
notify prescriber if unusual effects
occurs

Prepared by: CASTROVERDE, JOANNAH MARIE C.

CNS lethargy, hallucinations,

seizures

AMOXICILLIN
375mg TID

Infections due to susceptible

strains; helicobacter pylori
infections in combination with other
agents; post-exposure prophylaxis
Bactericidal: inhibits synthesis of
against bacillus anthracis
bacterial cell wall, causing cell
;Chlamydia trachomatis
death
in pregnancy

Culture infected area prior to

treatment; reculture area if
GI glossitis, stomatitis,
response is not expected>Give in
gastritis, sore mouth, furry
oral preparations only; amoxicillin
tongue (black hairy), nausea,
is not affected by food>Continue
vomiting, diarrhea (bloody),
therapy for at least 2 days after
signs of infection have
GU nephritis>Hematologic
disappeared; continuation for 10
anemia, thrombocytopenia
full days is recommended>Use
corticosteroids or antihistamines
Hypersensitivity rash, fever,
for skin reaction
wheezing, anaphylaxis

Prepared by: CASTROVERDE, JOANNAH MARIE C.