PLANNING (NURSING CARE PLANS)

Problem No. 1 Hyperthermia

Assessment Nursing Diagnosis Scientific explanation Objectives Interventions Rationale Expected Outcome

S>ø

O> patient manifested:

>Flushed warm skin

>Increase

Temp. of 38.5OC

>irritability

>Diaphoresis

patient may manifest:

Increased PR

Increased RR

Seizure

Muscle rigidity

Hyperthermia related to

inappropriate clothing factor

as evidenced by decrease

in platelet count.

Dengue Hemorrhagic Fever

is potentially deadly

complication that is

characterized by high fever.

Hyperthermia is an

abnormal rise in the

temperature of the human

body. Normal body

temperature is 98.6 OF or

37.5 OC. Fever may not

result only from a

disturbance of heat-

regulating mechanism of the

body but also through

disturbances of the blood,

the rate of breathing. Indeed

there are oral intake during

periods of illness will result

to further body weakness

impairing the patient’s ability

to perform usual routines

and ADL’s

Short term:

After 4 hours of Nursing

Interventions the patient’ will

be maintaining a normal

body temperature.

Long Term:

After 4 days of NI, the

patient will experience no

associated complications

such as seizures etc.

>Establish good working

condition with the pt and

SO.

>monitor v/s q 2hours.

>provide TSB

>Encourage increase fluid

intake

>Encourage food rich in

Vitamin C

>provide client safety

>maintain bed rest

>to gain patient’s trust

>to have baseline data

>to maintain a normal body

temperature.

>to replace fluid loss

>to boost body resistance to

infection

>to prevent further injuries

>to preserve energy

Short term:

The patient’s body

temperature shall have a

maintained normal body

temperature.

Long Term:

After 4days of NI, the patient

will experience no

associated complications

such as seizures etc.

Problem No. 2 ineffective tissue perfusion related to decrease hgb concentration

Assessment Nursing Diagnosis Scientific explanation Objectives Interventions Rationale Expected Outcome

S>ø

O> patient manifested:

ineffective tissue perfusion

related to decrease hgb

Due to the replication of

dengue virus in the body,

Short term:

After 3 hours of Nursing

> Establish good working

condition with the pt and SO

>to gain patient’s trust Short term:

After 3 hours of Nursing

>appears pale and weak

>flushed palms and soles

concentration there could be stimulation of

production of kinine causing

increase vascular

permeability leading to

capillary damage. Thus will

cause internal bleeding.

This was manifested

through flushed palms and

soles and appearance of

brownish purplish rashes on

the extremities

Interventions the patient’ will

demonstrate behaviors that

will improve thee tissue

perfusion.

Long Term:

After 2-3 days of NI, the

patient will demonstrate

increase tissue perfusion

AEB normal Hgb level count

>Assess the patient’s

condition

> Monitor vital signs

>assess for possible

causative factors r/t

temporarily impaired arterial

blood flow

>Monitor quality of all pulse

>maintain optimal cardiac

output

>review lab values and note

customary baseline data

>to have baseline data

>needed for ongoing

comparison

>early detection of cause

facilitates prompt, effective

treatment

>loss of peripheral pulses

must be reported or treated

immediately

>to increase cellular oxygen

supply

>to evaluate the importance

of NI’s given and provide

comparison by current

findings

Interventions the patient

shall have demonstrated

behaviors that will improve

thee tissue perfusion.

Long Term:

After 2-3 days of NI, the

patient shall have

demonstrated increase

tissue perfusion AEB normal

Hgb level count

Problem # 3: Risk for injury r/t abnormal blood profile as evidenced by decrease platelet count

Assessment Nursing Diagnosis Scientific explanation Objectives Interventions Rationale Expected Outcome

S>ø

O> patient manifested the

following which put his at risk for

injury

Low platelet count

Abnormal blood

profile

Tissue Hypoxia

Pt may manifest

Sensory dysfunction

Broken Skin

Malnutrition

Risk for injury r/t

abnormal blood profile

as evidenced by

decrease platelet

count.

Risk of Injury as a result of

environmental conditions

interacting with the

individuals adaptive and

defensive resources. It is

also because of the

infection of DHF I Virus

that destroys the platelets

which place the patient at

risk of bleeding. When the

blood vessels are cut or

damage , the loss of blood

from the system must be

stop before shock and

possible death may occur.

This is accompanied by

solidification of the blood, a

process called coagulation

or clotting. If the value

should stop below normal,

(150,000 -450,000 g/dl),

there is a danger of

uncontrolled bleeding

because of the essential

role that platelets have in

blood clotting.

Short term:

After 4 hours of Nursing

Interventions, pt will

demonstrate techniques

behavior, lifestyle

changes to risk factors

and protect self.

Long Term:

After 1 days of NI, the

patient’ will be free from

injury.

>Establish rapport

>Assess level of

consciousness and cognitive

level

>Provide safe environment

(pad, side rails, prevent falls)

> Observe for each stool color,

consistency and amount

>Observe for hemorrhagic

manifestation, ecchymosis,

epistaxis, Petechiae, and

bleeding gums

>Encourage intake of foods

with high content of Vit. C

> Assess pt’s condition and

monitor vital signs.

> Provide comfort measures,

such as stretching bed linens.

>to gain patient’s trust

>assist in determining pt.

‘s ability to protect self

and comply with required

self protective actions

> Minimizes injury to

occur

> Permits detection of

bleeding in GI tract

> Indicate altered clotting

mechanism

> Promotes healing and

boost the resistance of

the body against

infection

> To obtain baseline data

> To promote relaxation

and alleviate .

Short term:

After 4 hours of Nursing

Interventions, pt will have

demonstrate techniques

behavior, lifestyle

changes to risk factors

and protect self.

Long Term:

After 1 days of NI, the the

patient’ will have been

free from injury.

> Avoid SC, IM route of

injection as possible > Minimizes tendency of

trauma or bleeding

Problem # 4: Risk for constipation related to irregular defecation habits as evidence by defecate once or twice per week

Assessment Nursing Diagnosis Scientific explanation Objectives Interventions Rationale Expected Outcome

S=Ø

O= patient manifested by:

irregular defecation

habits

inadequate toileting

recent environmental

changes

>change in usual eating

pattern

>ignoring urge to

defecate

Patient may manifested by:

>dehydration

>electrolyte imbalance

>decrease motility of

gastro intestinal troat

>hemorrhoids

Insufficient physical

activity

Risk for constipation

related to irregular

defecation habits as

evidence by defecate

once or twice per

week

Irregular defecation habits

of one or two times per

week may cause the stool

to harden and dry. It may

also cause infection which

may lead to constipation

ST

After 3 hrs of nursing

interventions patient will

demonstrate behaviors

changes to developing

problem

LT:

After 2 hrs of nursing

interventions patient will

improve her bowel pattern

Provide comfortable

environment

Provide comfort measures by

AM care, changing the linen

and touch therapy

Provide safety by placing

pillows at the side of the bed

VS monitor and change

To ease patient’s anxiety

and to help the patient

recover faster for proper

hygiene of the patient

For proper hygiene of the

patient

To avoid patient from

injury

To have baseline data

Reflecting bowel activity

ST

Patient shall have

demonstrate behavior

changes to developing

problem

LT

Patient shall have

improve her bowel pattern

Auscultate abdomen for

presence, location and

characteristics of bowel

sounds

Review medication

Encourage balance fiber and

bulk habit

Promote adequate fluid intake,

including water and high-fiber

fruit juice; also suggest

drinking warm fluid

Ascertain frequency, color,

consistence, amount of stools

Educate client/SO about safe

and risky practice for

managing constipation

Review medical/ surgical

history

For impact effect of

change in bowel function

To improve consistence

of the stool and facilitate

passage through colon

To promote soft stool and

stimulate bowel activity

Provide as baseline of

comparison, promotes

recognition of changes

Information can help

client to make beneficial

choices when needed

To identify condition

commonly associated

with constipation

To determine if drugs

contributing to

Review appropriate use of

medication. Discuss client’s

current medication regimen

with physician

constipation can be

discontinue or change

Problem # 5 Impaired tissue integrity related to mechanical and chemical factor of IV infusion and blood test; secondary to haematoma as evidence by collection of blood on the upper extremities.

Assessment

Nursing

Diagnosis

Scientific

Explanation Objectives Interventions Rationale

Expected

Outcome

S=Ø

O= patient manifested by:

pallor

haematoma on

both upper

extremities

weakness

impaired

circulation

damage tissue

Patient may manifested by:

fluid deficit

infection

acute pain

change in turgor

edema

Impaired tissue

integrity related to

mechanical and

chemical factor of IV

infusion and blood

test; secondary to

haematoma as

evidence by collection

of blood on the upper

extremities.

Hematoma is a localized

collection of blood, usually

clotted, in a tissue or organ.

Hematomas can occur

almost anywhere on the

body. In minor injuries, the

blood is absorbed unless

infection develops. One of

the signs of haematoma is

collection of blood in the

peripheral area it may be

seen in the upper

extremities. Mechanical and

chemical factors like IV

infusion and blood test may

cause haematoma.which

leads to impaired tissue

integrity.

ST

After 4 hrs of nursing

interventions patient will

demonstrate behavior to

reduce the hematoma

LT

After 2 weeks of nursing

interventions presence of

hematoma will be reduce

Provide comfortable environment

Provide comfort measures by AM

care, changing the linen and

touch therapy

Provide safety by placing pillows

at the side of the bed

Encourage adequate periods of

rest and sleep

VS monitor and change

Identify underlying condition

involves in tissue injury

To ease patient’s anxiety and to

help the patient recover faster for

proper hygiene of the patient

For proper hygiene of the patient

To avoid patient from injury

To limit metabolic demands,

maximize energy and meet

comfort needs

To have baseline data

Suggest treatment options,

desire/ability to protect self and

potential to recurrence of tissue

ST

Patient shall have

demonstrate behavior to

reduce hematoma

LT

Patient shall have reduce

presence of haematoma

Assess skin/tissues, bony

prominences, pressure areas

and wounds

Inspect lesions/wounds daily, or

as appropriate, for change

Monitor laboratory studies

Help client and family to identify

effective successful coping

mechanisms and to implement

them

Discuss importance of early

detection and reporting of

changes in condition or any

unusual physical discomforts

Emphasize need to adequate

nutritional/fluid intake

Provide warm compress

damage

To comparative baseline

Promote timely

interventions/revision of plan of

care

To changes indicative of healing or

infection complications

To reduce discomfort and improve

quality of life

Promotes early interventions/

reduces potential complications

Optimize healing potential

To improve circulation