University of Pangasinan

PHINMA Education Network

College of Health Sciences

Patient’s Initials: LMM Age & Gender: 15 F Chief Complaint: fever Name of Student Nurse: Valdez, Jeremy Neil M.

Birthday: February 05, 2004 Admitting Diagnosis: Dengue without warning signs Level/block/group: 2 BSN – 6

Address: Pias, Mapandan, Pangasinan Hospital/area: Mapandan Community Hospital

Date of Confinement: August 3, 2019 Clinical Instructor: Carol Joy Paragas Date: 8/23/19

ASSESSMENT EXPLANATION OF THE PLANNING INTERVENTIONS RATIONALE EVALUATION

PROBLEM
Subjective data: Primary dengue virus At the end of the nursing Independent: Independent: At the end of the
Verbalized feeling very infection may lead to a care, the client will have nursing care the
warm, nausea, vomiting disease that includes restored normal fluid  Assess, document  Getting the baseline vital signs objectives were met
and body malaise fever, headache, muscle volume as evidenced by: and monitor vital will allow you to compare and and the client
Objective Data: and joint pain and skin -Good skin turgor signs note the progress in rehydration achieved normal fluid
Objective data: rash. Severe disease can -Moist mucous membranes  Assess skin turgor or decline to dehydration. volume as evidenced
 -V/S: develop which involves -Vital signs within normal and mucous  Poor skin turgor and dry mucous by:
 Temp=37.7 deg. C, severe bleeding, shock, limits membranes membranes signal decreased fluid  Good skin
 Respi=24 cpm, and hemorrhagic fever. -Decreased perspiration  Assess the color volume turgor
 Pulse=97 bpm, This also causes -Urine specific gravity and amount of urine  Dark scant and dark-colored urine  Moist
 BP=90/70mmHg dehydration from within normal range and specific gravity with decreased specific gravity mucous
 Diaphoresis vomiting, high fever and  Assess fluid intake denotes fluid deficit membranes
 Dry skin; mucous the loss of water in the and output  To note if patient is in need of  Vital signs
membranes; poor body.  Assess the fluid status taking in more fluids. within normal
skin turgor in relation to dietary  This is to determine if there is limits
NURSING DIAGNOSIS intake equal intake and output of fluids.  Decreased
 Encourage to drink  To help restore a normal fluid perspiration
Risk for fluid volume
prescribed amount of volume in the body.  Urine specific
deficit related to decrease
fluid intake.
fluid  A deficient fluid volume may alter gravity within
 Monitor electrolyte electrolyte levels normal range
results  Dry mucous membranes,
 Provide oral hygiene especially on oral cavity, may
cause peeling and oral hygiene
Dependent: may also promote interest in
drinking.
 Administer IV fluids
per doctor’s order Dependent:
 Administer
antipyretics  To help restore a normal fluid
(Paracetamol) per volume in the body.
doctor’s order  Paracetamol is the only drug
allowed to lower down the
temperature since NSAIDs may
increase the risk for bleeding.