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Medical Diagnosis : Dengue Hemorrhagic Fever

Nursing Diagnosis: : Risk for injury r/t abnormal blood profile as evidenced by decrease platelet count
Short Term Goal: After 4 hours of Nursing Interventions, pt will have demonstrate techniques behavior, lifestyle changes to risk
factors and protect self.
Long Term Goal: After 1 days of NI, the the patient’ will have been
free from injury.

Assessment Problem Scientific Nursing Rationale Evaluation

Reason Intervention
S>ø Decrease Because of the >Establish >to gain Goal Met:
O> patient platelet count. infection of DHF rapport patient’s trust The patient has
manifested the I Virus that demonstrated
following which destroys the >Assess level of >assist in the techniques o
put his at risk for platelets which consciousness determining pt. behavior ,
injury place the patient and cognitive ‘s ability to liestyle changes
 Low at risk of level protect self and and was abled to
platelet bleeding. When comply with be free from
count the blood required self injury.
 Abnormal vessels are cut protective
blood or damage , the actions
profile loss of blood

 Tissue from the system >Provide safe > Minimizes

Hypoxia must be stop environment injury to occur

Pt may manifest before shock (pad, side rails,

 Sensory and possible prevent falls)

dysfuncti death may
on occur. This is > Observe for > Permits
 Broken accompanied by each stool color, detection of
Skin solidification of consistency and bleeding in GI
Malnutrition the blood, a amount tract
process called
coagulation or >Observe for > Indicate
clotting. If the hemorrhagic altered clotting
value should manifestation, mechanism
stop below ecchymosis,
normal,(150,000 epistaxis,
-450,000 g/dl), Petechiae, and
there is a danger bleeding gums
of uncontrolled
because of the
essential role >Encourage > Promotes
that platelets intake of foods healing and
have in blood with high content boost the
clotting of Vit. C resistance of the
body against
> To obtain
> Assess pt’s baseline data
condition and
monitor vital
> To promote
> Provide relaxation and
comfort alleviate .
measures, such
as stretching
bed linens.

> Avoid SC, IM > Minimizes

route of injection tendency of
as possible trauma or

Medical Diagnosis : Dengue Hemorrhagic Fever

Nursing Diagnosis: Hyperthermia related to inappropriate clothing factor as evidenced by decrease in platelet count.
Short Term Goal: After 4 hours of Nursing Interventions the patient’ will be maintaining a normal body temperature
Long Term Goal: After 4 days of NI, the patient will experience no associated complications such as seizures etc.

Assessment Problem Scientific Nursing Rationale Evaluation

Reason Intervention
S>ø Hyperthermia. Hyperthermia is >Establish good >to gain Goal Met:
O> patient an abnormal rise working patient’s trust The patient’s
manifested: in the condition with body
>Flushed warm temperature of the pt and SO temperature has
skin the human body. decreased from
>Increase Normal body >monitor v/s q >to have 38.5OC to
Temp. of temperature is 2hours. baseline data 37.2OC.
38.5OC 98.6 OF or 37.5
>irritability C. Fever may >provide TSB >to maintain a
>Diaphoresis not result only normal body
patient may from a temperature
manifest: disturbance of
 Increased heat-regulating >Encourage >to replace fluid
PR mechanism of increase fluid loss
 Increased the body but intake
RR also through

 Seizure disturbances of

 Muscle the blood, the >Encourage >to boost body

rate of breathing. food rich in resistance to
rigidity Indeed there are Vitamin C infection
oral intake
during periods of >provide client >to prevent
illness will result safety further injuries
to further body
weakness >maintain bed >to preserve
impairing the rest energy
patient’s ability
to perform usual
routines and

Submitted by:
Mary Anne E. Elepaño
Group 11
Submitted to:
Ms. Renieses
Clinical Instructor
San ;Lazaro Hospital