Nursing Care Plan

Cues Subjective :Ang init init ng pakiramdam ko As verbalized by the client Objective: Temp = 39 C Flushed skin Warm to touch Nuring Diagnosis Hyperthermia related to physiological factors secondary to dengue hemorrhagic fever Analysis Body temperature elevated above normal level that is usually caused by several factors related to illness. As inoculation occurs, proliferation of virus follows and multiplication occurs. Once the virus starts to grow in number, it will soon reach it pathogenic level that will result into pyrexia or fever as a defense mechanism of the body. Nursing Objective After 4 hours of nursing intervention client will be able to maintain core temperature within normal range as evidenced by:- body temperature is lowered to 37 C Nursing Rationale Intervention Monitor vital signs Serves as baseline data Evaluation September 21, 2012 1:00pm GOAL MET After 4 hours of nursing intervention client was able to maintain core temperature within normal range as evidenced by:- body temperature is lowered to 37C

Perform tepid sponge bath

Heat loss by means of evaporation and conduction

Provide cool environment Maintain bed rest or minimize movementIncrease oral fluid intake

Heat loss by means of convection To reduce metabolic demands of oxygen consumption- to To prevent dehydration and support circulating volume To decrease the patients body temperature

Administer medications as ordered by physicians such as Paracetamol and other anti pyretic drugs

Objective: Irritable Poor skin turgor assessed at the abdomen Dry mucous membranes including the buccal and oral mucosa Passed out stool once in the mor ning. Stool was semisoft, yellow in color and not watery. BP= 120/80 mmHg CR=90bpm PR= 20cpmDeficient fluid

Deficit fluid volume related to the migration of intravascular fluid into extravascular fluid

Water content of the human body progressively decreases from birth to old age. In the neonate, fluid accounts for as much as 75% of body weight. Most of the decrease occurs in the first 10 years of life. Hypovolemia or extracellular fluid volume deficitis the isotonic loss of body fluids, that is, relatively equal losses of sodium and water. Pediatric clients are more at risk of hypovolemia and dehydration because their bodies need to have a higher proportion of water to total body weight. Excessive fluid loss reduced fluid intake, third-space fluid shift, and a combination of these factors causes

After an 8hour shift, client will be able to demonstrate adequate fluid balance as evidenced by good skin turgor, moist skin and mucous membranes

Note potential sources of fluid loss/intake

Causative/ contributing factors for fluid imbalances

September 22, 2012 12:00am GOAL MET

Continue monitor the vital signs, mucous membranes, weight, skin turgor, breath sounds, urinary and gastric output. Review patients intake of fluids. Hydrate with water after every feeding Determine childs normal pattern of elimination

Indicators of hydration After an 8-hour shift, client status was able to demonstrate adequate fluid balance as evidenced by good skin turgor, moist skin and mucous membranes

Provides baseline and comparison

Provides information for baseline and comparison

Continue monitor the patients weight and compare the result on the next days. Weigh on the same

Consistency with weight measurement helps ensure more accurate results. Weight is a useful indicator

fluid volume loss. Fluid loss causes include abdominal surgery, diabetes mellitus, diarrhea, vomiting, excessive diuretic therapy, excessive use of laxatives, excessive perspiration and crying, fever, fistulas, hemorrhage, nasogastric drainage and renal failure with polyuria.

scale at the same time of day &wearing same amount of clothing

of fluid balance. Weig ht loss indicates that child is not receiving adequate fluid replacement and adjustments need to bemade Provides fluid & nutritional support to replace active fluid loss. Close monitoring and regulation is required to prevent fluid overload while correcting fluid balance.

Administer and monitor IV fluids as ordered