APPENDIX: C NURSING CARE PLAN Patients Name: Age: ___Ms. R.A.M.N.C.______ Hospital No.:_20121613_____ Room No.

: CW-30___

_15 years old__________________ ___________

Impression: Dengue Fever

Physician: Dr. Sales, H.R. MD_

Nurses Name & Signature: Alvarez, Jermaine T. , UC-SN_ CLINICAL PORTRAIT I. Assessment Patient seen sitting on a chair, awake, conscious, weak and PERTINENT DATA I. History of present illness Ms. R.A.M.C.N., 15 years old, Filipino, Roman Catholic.

febrile, with IV line of PNSS 1L inserted at right arm @ Currently residing at Villa Sto. Nino, Inayawan , Cebu City . Her height 30gtts/min. infusing well. Patient is not in pain, no is 157.48 cm and weight is 39 kg. She is single. Ms. R.A.M.C.N. is still

respiratory distress noted. No dehydration present. No edema a 4th year student in St. Paul College. She was admitted on September noted and any lesions. II. Significant findings 9, 2012 at Visayas Community Medical Center for because of intermittent fever. The patient experiences 4 days of fever, on and off,

Patient is febrile, displays expression of weakness, there is muscular rash in extremities and back, muscle weakness but no pain at presence of dehydration evidenced by dry skin and no pain all. Her attending Physician is Dr. Sales, H.R. M.D. noted. II. Past health history

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III. Vital Signs T- 38.9 C P- 112 bpm R- 22 cpm Bp- 90/60 mmHg IV. Priority or Raw Nursing Diagnosis 1. Hyperthermia r/t increased metabolic rate, and

Patient has no previous hospitalization, has complete immunization and has no any drug or food allergies. Patients heredofamilial disease was hypertension, diabetes mellitus, and pneumonia (for more detailed information about the heredo-familial disease please refer to page 10). III. Chief complaint Patient came in for fever, muscular rash, and muscle weakness but no pain and edema noted. Signs of dehydration are present due to vomiting.

dehydration AEB decreased level of immune system. 2. Fluid volume deficit r/t active fluid loss AEB

vomiting, dry skin and mucous membranes and IV. Health history relevant to present illness: muscle weakness. 3. Patient experiences fever, muscle weakness and muscular rash

Diversional activity deficit r/t usual hobbies specifically in the extremities and in her back. There was no abdominal

cannot be undertaken in hospital AEB verbal pain noted. Dehydration is present evidenced by dryness of the skin and expression of boredom. 4. Risk for injury r/t abnormal blood profile AEB leukopenia, and decreased V. Vital signs taken during admission: mucous membranes and weakness.

thrombocytopenia, hemoglobin count.

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5.

Risk for shock r/t hypovolemia (decreased

T- 38.9C P- 112 bpm R- 22 cpm Bp- 90/60 mmHg

oxygen in blood) AEB decreased level of hemoglobin count.

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