ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

Objective: Hyperthermia Elevated body Short Term Assess intake and output, Early Detect dehydrated, and Short term
 Temp= related to the temperature due Goals: vital signs (temperature, knowing fluid and electrolyte goals:
41 deg. process of to a break in pulse, blood pressure) every balance in the body. Vital Signs Goal was met.
 BP= dengue virus After 5 hours of 3 hours once or more often. is a reference to determine the
thermoregulatio
90/80 infection as nursing patient's general condition.
n that arises
evidenced by intervention the
mmHg when a body
skin rashes patient will Perform TSB on patient. To lower down temperature
 Diaphore produces or maintains body
sis absorbs more temperature Administer intravenous Fluid replacement is essential
 Warm to
ASSESSMENT DIAGNOSIS heat RATIONALE
than it below 39° PLANNING fluids and INTERVENTION
medications as RATIONALE
for patients EVALUATION
with a high body
touch dissipates. It is a Celsius. ordered. temperature. Drugs specifically
 With skin sustained core to lower the patient's
Objective: Risk for This disease isLongShort
TermTerm Goals: Establish rapport and to gain patient’s
temperature. Short termLong
goals:term
rashes temperature
 Temp= 41 bleeding r/t manifested good working trust and
altered clotting beyond the by Goals:
a
After 6 hrs. of condition
Goal was met.
goals:
deg. sudden onset of Encourage patientswith the
to drink Tocooperation
replace fluids lost due to
 BP= 90/80 factor aeb normal variance, Afternursing patient. Goals was fully
fever, headache, 2-3 days plenty of 1500-2000 cc / day evaporation.
mmHg decreased usually greater of nursing interventions, the
(as tolerated)
met.
joint/muscle
platelet and than 39° C pt. will be able to Assess for signs and the G.I. track
 Diaphoresis pain, nausea intervention, the
hemoglobin (102.2° F). and demonstrate
patient will be Instruct symptoms
the patient ofto G.I.
wear To(esophagus &
provide a sense of comfort
 Plateler=45 count secondary vommiting
. and behaviors
maintains BP that clothingbleeding
that is thin and easy rectum)
and is the
easy thin most that
clothing
to dengue decreased in reduces
and HR withinthe risk
to for
absorb/nosebleeding.
sweat Note usual source
absorbs of does not
sweat and
hemmorhagic appetite. Rashes bleeding
normal limits. by: for color of stool, bleeding due to its in body
stimulate an increase
fever. and ecchymosis a.Gaining good vomitus and urine. mucosal
temperature.fragility
can be seen in appetite Long term goals:
the acute phase. b.Increase in fluid Provide Observe for presence
high caloric diet or Sub-acute diet is necessary
Appropriate Goalstowas fully
There may also intake of petechiae,
as indicated by the physician. disseminated
meet the metabolic demand met.of
be gastritis and c.Avoidane of dark ecchymosis, intravascular
the patient.
colored foods/fluids bleeding from one or coagulation (DIC)
bleeding
and eating food rich more sites. may develop sec. to
because of in vit. C altered clotting
altered clotting d.Eradication of factors.
ASSESSMENT DIAGNOSIS factors due to PLANNING
RATIONALE weakness/restlessne INTERVENTION RATIONALE EVALUATION
low platelet ssLong Term Monitor VS especially An increase
Objective: Deficient fluid When you count ShortGoals:
Term Assess, Pulse
documentand BP.
and in pulse
Getting thewith
baseline vital signs Short term
 Temp= volume r/t (thrombocypeni
experience a Goals: monitor vital signs decreased
will allow you blood
to compare and goals:
41 deg. increased fever,a)you may lead After 2-3 days of
thatoften pressure
note can in rehydration Goal was met.
the progress
 BP= metabolic state to worsening Afternursing
5 hours of orindicate
decline loss of
to dehydration.
suffer from
90/80 and insensible cases of DHF.nursing intervention, the circulating blood
loss secondary
increased patient will
intervention the Assess skin turgor and volume.
Poor skin turgor and dry
mmHg sweating which patient
to Dengue maintain optimal
will have mucous membranes mucous membranes signal
 Diaphore fever can lead to fluid restored gas normal
exchange. To prevent
decreased fluid volume
sis and electrolyte fluid volume as Remove sharp objects bleeding injury
 Dry skin; loss, and you evidenced by: Check theon color
bedside.
and amount Dark scant and dark-colored
mucous might eat or -Good skin of urine and specific gravity urine with decreased specific
membran drink less fluid turgor Advise to use soft To prevent
gravity denotesgums
fluid deficit
es; poor due to feeling -Moist mucous bristle toothbrush from bleeding. Long term
ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTION Rationale EVALUATION

Objective: Risk for Inability to Short Term Identify factors that are Choice of interventions Short term goals:
 Fever x 3 Imbalanced procure adequate Goals: contributing to nausea or depends on the Goal was met.
days Nutrition: Less amounts of food. vomiting: copious underlying cause of the
 Loss of Than Body After 8 hours of sputum, aerosol problem.
appetite Requirements nursing treatments, severe
Related to intervention the dyspnea, pain.
 Vomit x 2
decreased patient will
times
desire to eat demonstrate Provide a pleasant A pleasing atmosphere
 Pale, dry secondary to increased environment. helps in decreasing
skin nausea and appetite. stress and is more
 Muscle vomiting. favorable to eating.
weakness Long Term Long term goals:
and Goals: Advise small, frequent These measures may Goals was fully
tenderness meals, including dry enhance intake even met.
After 2-3 days foods (toast, crackers) though appetite may be
of nursing and/or foods that are slow to return.
intervention, the appealing to patient.
patient will
maintains/regain Promote proper Elevating the head of
s desired body positioning. bed 30 degrees aids in
weight. swallowing and reduces
risk for aspiration with
eating
.
Encourage family Patients with specific
members to bring food ethnic or religious
from home to the hospital. preferences or
restrictions may not
consider foods from the
hospital.
Evaluate general
nutritional state, obtain
baseline weight. Presence of chronic
conditions an contribute
to malnutrition, lowered
resistance to infection,
and/or delayed response
Once discharged, help the to therapy.
patient and family
identify area to change Change is difficult.
that will make the greatest Multiple changes may
contribution to improved be overwhelming.
nutrition