DENGUE HEMORRHAGIC FEVER – Risk for Injury

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective: Risk for After 2 hours - Monitor vital sign - To obtain baseline data After 2 hours
- Febrile injury of nursing especially BP and and an increase in of nursing
- Flushed skin related to intervention PR pulse with decreased intervention
- Skin warm to hemorrhage the client will BP can indicate loss of the client
touch be able to circulating blood demonstrated
- Chills demonstrate volume. behaviors that
- Sweating behaviors - Increase fluid intake - To prevent dehydration reduced the
- V/S: that reduce - Provide TSB - To reduce temperature risk for
PR: 115bpm the risk for - Promote bed rest - To reduce metabolic bleeding
RR: 26cpm bleeding demand or oxygen
T: 39.8°C consumption
BP: - Encourage use of - In the presence of
130/70mmHg soft toothbrush and clotting factor
forceful nose blowing disturbances, minimal
trauma can cause
mucosal bleeding
- Use small needles - Minimizes damage to
for injections. Apply tissues, reducing risk
pressure to for bleeding and
venipuncture sites hematoma
for longer than usual
- Assess for signs and - The G.I tract is the
symptoms of G.I most usual source of
bleeding. Check for bleeding
secretions. Observe
color and
consistency of stools
or vomitus.