Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur
BACHELOR OF SCIENCE IN NURSING
College of Health Sciences
Instruction: Using the given data, please complete the Nursing Care plan.
Activity # 1: NURSING CARE PLAN
Name: Patient X Age: 25 years old Date: August 20, 2021
Address: Barangay Uno Clinical Diagnosis: Dengue Hemorrhagic Fever
Nursing Nursing
Cues Rationale Planning Rationale Expected Outcome
Diagnosis Intervention
Subjective: “Isang araw 1. 2. Short term: 4. 5. 6. After 6 hours of
parang dumugo ilong ko Injury, risk for To help avoid After 6 hrs of nursing Advise the patient to The G.I tract is the nursing intervention
hemorrhage fatigue and to intervention, the client take some rest. most usual source the client will be able
pero konti palang
related to nose will be able to identify of bleeding. to demonstrate
naman”as verbalized by improve proper
individual risk and Advise patient to eat behaviors that reduces
the Patient. bleed. lifestyle to engage in appropriate leafy foods and drink The respiratory rate the risks for bleeding.
prevent from behaviours or lifestyle supplements. is high and the pulse __________
______________
Objective: Weakness and bleeding. changes to prevent rate is considered
irritability. · Restlessness. ______________ bleeding. Assess and monitor the normal. The
temperature. temperature is high
·
Long term: Monitor the respiration considering having
- V/S taken as follows: 3. rate. a fever.
BP= 120/80 mmHg CR= After 24 hours the Monitor the pulse rate. _____________
90bpm patient will be able
PR= 20cpm Note changes in the
to maintain his/her
Temp: 37.8 C level of consciousness.
health and the need _________________
to rest. (Write down all
Platelet Count - 66 ________________ possible interventions
independent/dependent
related to the problem
and plan) Ex:
(List at least 8)  Increased
heart rate
and
Ex: orthostatic
 Assess and changes
Monitor vital accompany
signs bleeding
  Advise patient
to avoid dark
colored foods
Prepared by: Submitted to:
Hesita, Bea Teresa F.
_______________________________ ____________________________________
Student Clinical Instructor