Subjective Objective Cues Nursing Analysis Scientific Analysis Planning Intervention Rationale Evaluation

Cues

Decreased WBC Ineffective tissue A mosquito which carries Short Term: Establish Rapport To gain pt’s trust The pt shall have
perfusionrelated the dengue virus is called After 4 hours of NI, Monitor Vital Signs To obtain baseline demonstrated
Aedes aegypti. The said
Decreased platelet to decreased mosquito comes in
the pt will data behaviours to
HgB contact with a person and demonstrate Assess patient’s improve circulation
Decreased HgB concentration in bites the person. The behaviours to improve condition To assess The pt shall have
the blood dengue virus will flow circulation. contributing factors demonstrated
secondary to through the blood stream increased perfusion
Decreased capillary and destroys blood Note customary
refill time DHF 1 components. Patients Long Term: baseline data For comparison with as appropriate
with dengue often has current findings
Altered LOC decreased WBC, platelet  After 4 days of Determine presence
& haemoglobin count. NI, the pt will ofdysrhythmias To identify
Hemoglobin count is used
Fever to measure oxygen demonstrate alterations from
Source: carrying capacity of the increased Perform blanch test normal
Marlin E. blood. Hemoglobin perfusion as
Chills
Doenges, Mary carries oxygen. appropriate To identify /
Check for Homan’s
Frances Therefore, if there is
Diaphoresis decreased haemoglobin, sign determine adequate
MOorhoose, perfusion
there is also decreased
alice C. Murr, oxygen that reaches the Note presence of
Nurse’s Pocket different tissues of the bleeding To determine
Guide, 10th body.
presence of
edition
Elevate HOB thrombus formation
pp.388-394
Encourage quiet & To determine risk of
restful atmosphere anemia

Instruct to avoid To promote

tiring activities circulation

Encourage light To promote comfort

& decrease tissue
 ambulation O2 demand

Encourage use of To decrease cardiac

relaxation workload
techniques
To enhance venous
Administermedicati return
ons
To decrease tension
andanxiety level

To treat underlying
cause

Subjective Objective Cues Nursing Analysis Scientific Analysis Planning Intervention Rationale Evaluation
Cues
When a person comes in Short Term:
“ > Temp of 39.8 contact with a mosquito, After 4 hours of NI, Establish Rapport To gain pt’s trust The pt shall have a
Aedes aegypti, the
Hyperthermia dengue virus flows
pt’s temperature will Monitor Vital Signs To obtain baseline decreased body
> Flushed skin through the blood stream. decrease from 39.8 to data temperature from
As the compensatory 37. Assess neurologic 39.8 to 37
> Skin warm to mechanism of the body, it response, note LOC To evaluate effects The pt shall have
will raise its temperature identified underlying
touch Long Term: & orientation, & extent
to allow the immune
system to work better and reaction to stimuli, ofhyperthermia factors and
> Chills to deteriorate the  After 3 days of papillary reactions importance of
Source: condition of the invaders NI, the pt will & presence of To monitor heat & treatment as well as
Marlin E. thus identify seizures fluid loss s/sx requiring further
The pt. May causing hyperthermia.
manifest Doenges, Mary underlying evaluation or
Frances factors & Note presence / To minimize intervention
> Increased RR MOorhoose, importance of absence of sweating shivering
alice C. Murr, Presence of treatment as well
Nurse’s Pocket microorganisms as s/sx requiring
> Tachycardia Wrap extremities To reduce body
stimulates the release of
Guide, 10th pyrogen from the
further evaluation with bath towels temperature
> Convulsions edition leukocytes resetting the or intervention
pp.388-394 body’s thermostat to Provide TSB q 15 To reduce body
febrile level and then minutes temperature in areas
> Sweating
there would be activation
of the hypothalamus, of high blood flow
which will result in Apply local ice
increase in epinephrine packs in axilla To reduce metabolic
and norepinephrine, demands / oxygen
vasoconstriction of
Instruct client to consumption
cutaneous vessels. The
heat will be produced as have bed rest
peripheral vasodilation To prevent
results in skin flushing Instruct client to dehydration
and skin is warm to
increase OFI
touch.
To support
Administer circulating blood
replacement fluids volume and tissue
perfusion
Administer
antipyretics To restore normal
body temperature
Reassess
temperature q 15 To determine
minutes effectiveness of
interventions
done