Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

SUBJECTIVE : Nahihilo po ako, Nauuhaw at nanlalata as verbalized by the client.

Fluid Volume Deficit R/T Intravascular to Extravascular Plasma Leakage Secondary to Increase in Vascular Permeability.

OBJECTIVE : - Sunken, Dry eyes - Pale palpebral conjunctiva - Dry lips and mouth - Prolonged Capillary refill time [ 7 seconds ] - Poor skin turgor - Rapid, Thready Pulse Heart rate 110 Bpm RR 21 Bpm BP 90/60 Temp 39.2 C

After an hour of spontaneous fluid replacement, Patient will gradually abate signs and symptoms of fluid volume deficiency as evidenced by increasing blood pressure, decreasing heart rate, improving capillary refill time preferably below 5s and an improving skin turgor.

1. Anticipate fluid replacement by preparing peripheral route for IV transfusion.

* IV transfusion is a dependent nursing function. Anticipate doctors order by providing route for IV fluid replacement to save time and decrease risk for complications. * IV is considered as MEDICATION. Before initiating IV Replacement therapy, make sure that there is a current standing or verbal order from the doctor. * placing a glass of water or juice at patients bedside is the best way to encourage fluid intake. DHF patient are always thirsty prior to the defervescence stage.

2. Obtain doctors order for IV therapy As soon as possible to replace fluid volume loss IMMEDIATELY.

After an hour of intervention, Patients BP increased to 100/70, Tachycardia resolved as evidenced by a normal HR of 80bpm. CRT decreased from 7s down to 4s and there is a noticeable improvement in the clients skin turgor

3. Encourage fluid intake by placing a glass of juice or water within the patients reach.

4. Monitor total fluid intake and output every 2 hours.

*A urine output of .5 ml per kg/hr is insufficient for normal renal function and indicates onset of renal damage * Monitoring for trends for 2 to 3 days gives a more valid picture of the client's hydration status than monitoring for a shorter period. Darkcolored urine with increasing specific gravity reflects increased urine concentration. * To monitor and assess clients response and progress in the fluid replacement therapy

5. Watch trends in output for 3 days; include all routes of intake and output and note color and specific gravity of urine.

6. Monitor vital signs of clients with deficient fluid volume every hour. Observe for decreased pulse pressure first, then hypotension, tachycardia, decreased pulse volume, and increased or decreased body temperature

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

SUBJECTIVE : Ang sakit po ng tiyan ko pati mga tuhod ko at binti as verbalized by the client. OBJECTIVE : - Diaphoresis - Pupillary dilatation - Cold Clammy skin - Apparent loss of appetite A documented pain scale of 6 on Pain scale. Heart rate 125 bpm RR - 34 bpm

Acute Pain R/T Massive endothelial tissue damage Secondary to pyrogenic dissemination

After 2 hours of nursing interventions, Patient will describe the pain as tolerable with minimal and manageable side effects. Pain scale using should range from 0 to 4 and patient should show a decreased sign of pain induced parasympathetic stimulation.

1. Administer Acetaminophen at minimal dosage as ordered.

* Dengue patients experience hepatomagaly which suggests liver overcompensation that impairs drug metabolism, Acetaminophen should be given at minimal therapeutic dose. * To detect if the condition is improving or worsening, Or if there is a need to increase the dosage of the medication. * To promote adequate rest and sleep periods that will prevent fatigue and decrease severity of pain. * To decrease patients perception of pain and increase his tolerance to pain. This will also

After 2 hours of nursing interventions, The patient verbalized Hindi na po masyadong masakit ang katawan ko pati yung mata ko at tuhod Re assessing Pain scale revealed a score of 2. Diaphoresis is not anymore evident. Patient skin is now warm to touch

2. Carefully monitor patients response to the medication by assessing the client

3. Provide a quiet environment conducive to resting and sleep.

4. Provide non pharmacological comfort measures like deep breathing exercises, guided imagery, praying

and distractions like story increase the childs telling and listening to a adaptive pain soothing music behaviour.