NURSING CARE PLAN

Cues Nursing Diagnosis Rationale to Nursing Goals and Nursing Rationale to Nursing Evaluati
Diagnosis Objectives Interventions Interventions on
Hyperthermia Some patients with Short term: Independent: After 4 hours of
Subjective cues: related to dengue fever go on After 4 hours of  Provide tepid  Enhances heat comprehensive
“Makuri ako inappropriate to develop dengue comprehensive sponge bath loss by nursing intervention,
makakaturog ha gab e, clothing factor as hemorrhagic fever, a nursing intervention,  Monitor V/S evaporation the patient will:
kai gin uubo ako tulo evidenced by severe and the patient  Assess fluid and  Maintain
na ka adlaw. Masuol
an akun dughan. decrease in platelet sometimes fatal form temperature will loss and conduction normal
Mapaso tak pag abat count secondary to of the disease. lower down to facilitate oral temperature
tulo na ka adlaw ngan dengue hemorrhagic normal levels: T: 36.5 intake  Notes progress of 37.5
gin kukurian ako
danay pag ihi” as fever.  Dengue degrees C–  Promote bed and changes of degrees C
verbalized by the fever is an 37.5degrees C rest condition  Be free of
patience. acute febrile  Provide cool dehydration
disease caused circulating air  Increase  Maintain vital
by infection wi using a fan metabolic rate sign at normal
th one of the  Assist patient and levels
Objective Cues: serotypes of in changing diaphoresis  Be alert and
the dengue into dry responsive
Temperature: 39.3 virus. It is a clothing  Reduces body  Be
degrees C mosquito-  Provide oral heat comfortable in
borne disease Long Term: hygiene production bed
Pulse: 122 caused by the After 3 days or
beats/min. genus Aedes. appropriate nursing Dependent:  Dissipates heat Long term:
Respiration: 32/min  Dengue is also intervention the  Maintain IV by convection 1 day of nursing
known as patient’s vital sign fluids as intervention the
 Skin pale Breakbone will return to normal ordered by  Increases patient’s vital signs
Fever, range with a physician comfort returned to normal
 Chills, used of temperature 36.5 –
Hemorrhagic
 Fever, Dandy 37.5 degrees C, pulse  Administer range
accessory Fever, rate of 60 – 100bpm antipyretic as  Prevents
muscles, Infectious and respiratory rate ordered herpetic lesion
inspiratory Thrombocytop of 12-20 cycles per of the mouth
 Administer
crackles with enic Purpura. min. antibiotic as
diminished  Dengue ordered.  Prevents
breath sounds hemorrhagic  Administered dehydration
right base. fever is a fatal paracetamol as
 Increase heart manifestation ordered.  Reduces fever
rate of the dengue
virus that  Treats
 Increase manifests with underlying
Respiratory bleeding cause
rate. diathesis
 Body and hypovole Collaborative:
temperature mic shock.  Monitor
above the  These viruses hematologic
normal range are related to test and other  Indicates
 Hot, flushed the viruses patient lab presence of
skin that cause the records infection and
West Nile dehydration
Weight: 42 infection  Ensure
Height: 149cm and yellow  Discuss continuous
fever. condition of intervention
Reference: the patient
Diagnostic Data: Fundamental of with other
nursing members of
Urinary test infection
- Harry & Peery the health care
to consider dengue
fever. team.

WBC: 14.47
RBC Count: 4.60
Hemoglobin: 133
HCT:37.9
MCU: 82.4
MCH:28.8
MCHC: 350
O2 SAT: 97%