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NURSING CARE PLAN

Date
and Assessment Need Nursing Diagnosis Goal of Care Nursing Interventions Evalu
Shift ation

Dec. Subjective: P Altered Within 4 INDEPENDENT: After

12, “Init kaayo akong H Thermoregulation: hours of 1. Monitored core temperature. 4
2010 lawas.” As Y hyperthermia r/t providing ® to serve as baseline data hours
verbalized. S illness secondary nursing care, 2. Provided continuous Tepid Sponge Bath. of
3-11 I to Dengue Fever hyperthermia ® to aid in lowering down high temperature by evaporation provi
-droopy eyes O will be and conduction ding
-dry, cracked lips L Rationale: Dengue managed as 3. Promoted surface cooling by means of changing nursin
noted O Fever is a severe, evidenced by: clothing into light ones. g
-weak facial and G potentially deadly ® to promote heat loss by radiation and conduction care,
body movement I infection spread by a. 4. Applied cotton with water on cracked lips regularly. @
-flushed skin C certain species of Temperature ® to bring back moisture on lips. 8:00p
noted mosquitoes, the within normal 5. Advised to increase oral fluid intake within level of m,
-skin very warm N illness itself causes range cardiac tolerance. GOAL
to touch E several symptoms b. absence of ® to support circulating volume and tissue perfusion PARTI
- petehial rashes E including flushed skin 6. Provided with a cool environment such as turning on the ALLY
noted on upper D alterations in c. absence of electric fans. MET;
and lower - thermoregulation. dry, cracked ® to promote heat loss by convection and proper as
extremities lips ventilation evide
-with good skin Reference: 7. Provided with adequate rest and sleep. nced
turgor www.umm.edu/en ® to reduce consumption of energy. by:
-with symmetrical cy/article/001373. 8. Advised to eat nutritional foods.
chest expansion T htm ® To boost immune system.
-capillary refill of H DEPENDENT: a.
less than 3 E 9. Administered antipyretics as ordered. Tempe
seconds R ® As pharmacological method of treatment. rature:
VS: M 37.3
T- 39.3 O ○C
RR- 26 R b.
CR- 98 E absen
BP- 110/80 G ce of
U flushe
L d skin
A
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T noted
I c.
O absen
N ce of
dry,
crack
ed
lips
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Date and
Shift Assessment Need Nursing Diagnosis Goal of Care Nursing Interventions Evaluation

Dec. Subjective: “luya S Risk for impaired Within 8 INDEPENDENT: After 8 hours
12, kau ako lawas” A skin integrity r/t hours of 1. Monitored vital signs. of providing
2010 As verbalized. F presence of rashes providing ® to serve as baseline data nursing care,
E secondary to nursing care, 2. Changed position on bed/ chair regularly.
@ 11:00pm,
3-11 Objective: T Dengue Fever skin integrity ® A part of the body stayed touch on a specific surface for
- dry, cracked lips Y a long period of time can cause heat and irritation. GOAL MET;
will be
noted Rationale: Dengue maintained at 3. Advised to increase oral fluid intake within level of as evidenced
- flushed skin A Fever is a flu-like optimal level cardiac tolerance. by:
noted N illness spread by as evidenced ® To maintain proper hydration.
- petechial rashes D the bite of an by: 4. Practiced proper handwashing technique in handling the
noted on face, infected mosquito. patient and between therapists.. a. With
abdomen, trunk Dengue fever is a a. maintain ®. To deter the spread of microorganisms. good skin
and extremities S severe and often good skin 5. Kept clothings, bed linens dry and free of wrinkles. turgor
- with good skin E fatal. Its turgor ® to prevent irritation of skin. b. Petechi
turgor C manifestation 6. Emphasized importance of adequate nutritional and
al rashes
- capillary refill U includes high b. Reduction fluid intake.
return within 3 R ® to maintain general good health and skin turgor.
reduced
fever, rash, severe of petechial
seconds I headache, pain rashes 7. Suggest use of calamine lotions.
- T behind the eyes ®to decrease irritable itching.
VS: Y and muscles and c. Vital signs
T- 39.3 joint pain, when maintained
RR- 26 - these rashes within normal
CR- 98 become severe, it range
BP- 110/80 S can cause T-36-37.4
K alteration in the RR-16-20cpm
I skin: impaired skin CR- 80-90
N integrity bpm
Bp-110/60-
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I Reference: 140/90 mmhg

N http://www.dhpe.o
T rg/infect/dengue.h
E tml
G
R
I
T
Y
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