NAME: Thea Demonteverde HOSPITAL: San Pedro Hospital AGE: 4

CHIEF COMPLAINT: PHYSICIAN: Dr. Estoque SEX: Female

DIAGNOSIS: Dengue ROOM & BED #: 206 - 5

DATE/ CUES NEED NURSING OBJECTIVES OF NURSING INTERVENTIONS EVALUATION

TIME DIAGNOSIS CARE

H Risk for injury: At the end of my 8 1. Establish a rapport and a trusting August 15, 2009
A E hemorrhage related to hours span of care, my
patient will be able
relationship with the patient.
R: Establishment of rapport and a trusting @
Objectives: decrease platelet count
U Weakness
A
secondary to dengue demonstrate relationship gains the trust and cooperation
L behaviors of the patient. 11:00 p.m.
Irritability fever
G T that reduces
the risk for bleeding 2. Monitor pulse, Blood pressure.
U Platelet count: 45 H R: This infectious such as: R: An increase in pulse with decreased GOAL MET.
disease is Blood pressure can indicateloss of
S manifested by a. Vital signs circulating blood volume. After my 8 hours span of
P a sudden
T E onset of fever,
within normal
range 3. Assess for signs
care, my patient was able
to demonstrate behaviors
with severe b. Be free of injury
R and symptoms of bleeding. that reduces the risk for
headache, c. Verbalize R: To provide proper intervention if bleeding as evidenced by:
1 C muscle and
joint pains
understanding symptoms persists. Bleeding indicate
E of individual dengue hemorrhagic fever a. vital signs within
5 P
(myalgias and
arthralgias—
factors that normal range
contribute to 4. Observe for presence of petechiae, Temp.: 3 °C
T severe pain possibility of ecchymosis, bleeding from one more sites. CR: bpm
gives it the
2 I
name breakbone
injury and take
steps to correct
R: Sub-acute disseminated intravascular
coagulation (DIC) may develop
PR: bpm
O fever or RR: 26 cpm
0 N bonecrusher
situation(s) secondary to altered clotting factors. BP: 90/60 mm Hg
 disease) and d. Demonstrate
0 A rashes and behaviors, 5. Encourage use of soft toothbrush, b. was free of injury as
9 N
usually
appears first
lifestyle
changes to
avoiding straining for stool, and
forceful nose blowing.
evidence by no wounds
nor damage seen upon
D on the lower reduce risk R: In the presence of clotting factor assessment;
limbs and the factors and disturbances, minimal trauma
@ H
chest. There protect self from can cause mucosal bleeding.
c. “dapat po mag-ingat
may also be injury.
E gastritis and tska wag masyadong
6. Use small needles for injections. Apply
some times malikot at magpagaling
3:00 A
bleeding.
pressure to venipuncture
sites for longer than usual.
po.” as verbalized by
L
R: Minimizes damage to tissues, the patient; and
T reducing risk for bleeding and hematoma.
PM H
d.Demonstrated
7. Recommend avoidance of aspirin behaviors, lifestyle
containing products. changes to reduce risk
R: Prolongs coagulation, potentiating risk factors and protect self
3-11 M
A of hemorrhage. from injury such as
staying in the bed and
Shift N 8. Tell patient not to do extraneous work. regains strength rather
A ® To prevent fatigue and injury. than playing on moving
around the room.
G
9. Administer platelet as indicated
E R: to replace the platelet loss in the body
M which provides clotting factor
E
10. Monitor Hb and Hct and clotting factors.
N R: Indicators of anemia, active bleeding, or
T Impending complications.