Assessment Diagnosis Planning Inference Implementation Rationale Evaluation

 Subjective Hyperthermia After 2 hours Body temperature Independent: After 4 hours of

“Ang init init ng related to of nursing elevated above - Provide tepid -Heat loss by nursing
kapatid ko inappropriate intervention normal level that is sponge bath means intervention
kapag clothing client will be usually caused by of evaporation goals and
hinahawakan” factor as able to several factors and conduction. objectives was
As verbalized evidenced maintain core related to illness. met as
by the patient’s by decrease temperature As inoculation -Promote surface -Heat loss by evidenced by:
sister. in platelet within normal occurs, proliferation cooling by means means
count secondary range as of virus follows and of undressing of radiation and -Body
to dengue evidenced by: once the virus starts conduction temperature
hemorrhagic - body to grow in number, lowered to 37
 Objective fever. temperature is it will soon reach - Provide cool -Heat loss by degree celcius.
- V/S taken as lowered to 37 it pathogenic level environment means
follows degree celcius. that will result of convection
into pyrexia or
T- 38 degree fever as a defense -Maintain bed - To reduce
celcius mechanism of the rest or minimize metabolic
PR- 88 bpm body. movement demands of
RR-22 cpm oxygen
BP-110/70 consumption
mmHg Reference: Nurse’s
pocket guide by - Discuss - To prevent
- Flushed skin Marilyn importance dehydration
- Warm to Doeges10th edition of adequate fluid
touch intake particularly
to the parents.

- Strictly monitor - To know if the

temperature patient’s
temperature
went down to
the normal
 value.

-Increase fluid - To lower the

intake temparature

Dependent:
Administer - To alleviate
paracetamol as the fever of the
prescribed by the patient.
physician.

Collaborative:
Refer to the - To monitor
physician if the patient’s
temperature still condition.
higher to normal
range.
Assessment Diagnosis Planning Inference Implementation Rationale Evaluation
 Subjective Risk for -After 3 hours of nursing Most dengue -Assess the signs and -The GI tract is the -After 3 hours
“Dumudugo hemorrhage interventions, the client infections symptoms of most usual source of nursing
yung labi ng related to will be able to result in GI bleeding. of bleeding of its interventions, the
kapatid ko” altered clotting demonstrate behaviors relatively -Check mucosal fragility client’s sister is able to
As factor. that reduce the risk of mild illness, for secretions. demonstrate behaviors
verbalized bleeding but some can -Observe color and that reduce the risk
by the progress to consistency of stools of bleeding.
patient’s dengue or vomitus.
sister hemorrhagic
 Objective fever. With -Observe for -Sub-acute
-Weakness and dengue presence of petichiae, disseminate dintra-
irritability hemorrhagic ecchymosis, bleeding vascular
-Restlessness fever, the from one more sites. coagulation may
-V/S taken as blood vessels develop secondary
follows: start to leak to altered clotting
T- 38.1 and cause factor.
PR- 90 bpm bleeding from
R- 22 cpm the nose, -Monitor pulse, BP -An increase in
BP- 110/70 mouth, and pulse with decrease
mmHg gums. BP can indicate
Bruising can loss of circulating
be a sign of blood volume
bleeding
inside the -Note changes in -Changes may
body. level indicate cerebral
Without of consciousness. perfusion problems.
prompt
treatment, the -Encourage use of -Minimal trauma
blood vessels soft toothbrush. can cause mucosal
can collapse, Avoid straining in bleeding
causing shock stool, and forceful
(dengue nose blowing.
shock -Use small needles -Minimize damage
syndrome). for injections. to tissues, reduce
Apply pressure to risk for bleeding
veni puncture sites and hematoma.
for longer than usual.

Dependent:
Don’t administer - To prevent
aspirin. spontaneous
bleeding.

Collaborative:
Check for platelet
count.

Check for -To know the

hematocrit. patency of the
hematocrit.
Report to
physician if
there’s a
continuous
bleeding.
Assessment Diagnosis Planning Inference Implementation Rationale Evaluation
Subjective: Acute pain and Long term: Pain Independent To rule out After 2 hours
“Sinasabi ng kapatid ko discomfort After 2 hours modulation 1. Assess worsening of of nursing
masakit daw tapos tinuturo related to dengue of nursing refers to the client’s underlying interventions, the
niya yung tyan niya” As hemorrhagic interventions, function of response to condition/ client was able to:
verbalized by the fever. As the client will neural cells to pain: development a. Report that her
patient’s sister. evidence by be able to: inhibit, reduce, of pain was
VAS of 5 out of or dampen the complications relieved from a
Objective: 10. a. Verbalize intrinsic pain scale of 5 to
Facial grimace reports that modulatory Pain is 1 out of 10.
Clenching of fists provide relief. activity of the -Perform pain subjective and b. Demonstrate
Pain scale of 5 out b. Demonstrate central nervous assessment cannot be felt duse of
of 10. use of system, thus each time pain by others relaxation
Vital Signs: relaxation reducing the occurs. skills and
BP-110/70 skills and painful stimuli. Observations diversional
PR-88 diversional Perception is -Accept client’s may not be activities.
RR-22 activities as the conscious description of congruent with
T-37.6 indicated for awareness, pain verbal reports.
VAS-5 out of 10 individual usually -Observe
situation. localized in nonverbal cues
certain areas of Usually
Short term: the body. -Monitor vital altered in
After 30 Level of pain signs acute pain
minutes of perception
nursing depends on
intervention the factors such as 2. Assist client
patient can: personal to explore
a. Report pain is experiences, methods for
relieved/ immediate alleviation/cont
controlled environment, rol of pain:
from a pain and socio- -Work with
scale of 5 to 1 cultural client to
out of 10. influences. prevent pain.
-Provide quiet
environment,
calm
activities

-Provide
comfort
measures like
change of
positions.

Dependent:
Administer
pain medicines
–Nuprin as
prescribed by
the physician.

Collaborative:
Check results
of the platelets
of the patient if
it’s already
higher than the
previous
laboratory.