DENGUE CASE PATIENT

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION/ RATIONALE EVALUATION

INTERVENTION
SUBJECTIVE: SHORT TERM: INDEPENDENT:
Hyperthermia related The goals are met. After
“Mainit po siya sir. to the process of Short term:  Acquire baseline  to identify thorough nursing
Wala din pong gana Dengue virus Vital Signs initial/current state of
kumain at masakit ang After 15-30 minutes of the patient; serves as intervention the patient
infection as
katawan” nursing intervention, the a comparison for was able to:
evidenced by increase
As verbalized by the patient’s body changes during the
body temperature, temperature will process
patient
warm and flushed decrease from 37.9 C to  To identify and
 Monitor Vital Signs
skin 36-37.2 C. monitor changes
during the procedure
OBJECTIVE: LONG TERM:  Monitor Input and  To identify if patient is
 Skin is warm to experiencing
output of patient, such
touch dehydration due to
After 8hrs of nursing as, sweating,
 Flushed skin increase body temp,
intervention, the patient urinating, diarrhea
 Lethargic will be able to maintain a and vomiting and possibility of
normal body electrolyte imbalance
Vital signs temperature.  To decrease body
 Perform Tepid Sponge
Temp- 37.9 C temperature
bath
Pulse rate- 100
bpm
Respiratory rate- 44
 Encourage the patient  Hydrating the body is
to drink plenty of one way of decreasing
cpm
water body temperature
Blood Pressure-
90/60 mmHg
(pakitingin sa  Maintain proper  Environmental factors
ventilation for the affects the body
chart)
patient temperature of the
patient
  To reduce metabolic
 Encourage bed rest demands of the
patient, increase
metabolic demand is
increase body
temperature

DEPENDENT:

 Administer  To reduce body

medications as temperature and To
ordered, antipyretics control shivering and
and diazepam seizures
 Administer Fluid  To replace fluid loss,
replacements, IV and maintain body
therapy temperature

COLLABORATIVE: