NURSING CARE PLAN

Name: Adrian Eugenio Age: 20 years old Diagnosis: DHF II

Subjective:
ASSESSMENT DIAGNOSIS AedesINFERENCE
Aegypti (Dengue GOAL INTERVENTION RATIONALE EVALUATION
virus carrier) 8-12 days Short Term Goal: Independent After 1 hour of
“Nangangati ako. Risk for impaired viral replication on rendering effective
Kanina ko pa to skin integrity mosquistoes’ salivary After 1 hour of -Monitor vital signs - Serves as nursing intervention
kinakamot eh.” As related glands nursing intervention, baseline the goals are fully met
verbalized by the to altered patient will data to as evidenced by
patient circulation demonstrate determine patient’s
Bite from mosquito behavior in preventing any demonstration of
skin impairment as discrepancies behavior in
Objective: evidenced by: preventing skin
-VS taken: Allowing dengue virus to - Determine client’s risk - Prompt impairment by applying
BP – be inoculated towards a. application of for skin breakdown identification of measures in preventing
110/90mmHg the circulation measures in using a risk assessment the client’s risk friction of the skin and
Temp. – 37.7˚C preventing tool for skin how to prevent the
RR – 22 bpm friction of the breakdown leads drying of the skin.
PR – 115 bpm Virus disseminated skin as well as to earlier
rapidly into the blood scratching. implementation After a week of nursing
- Redness of the and stimulates b. Following of actions to intervention the goals
skin WBC including B measures to maintain skin are fully met as
- Skin rashes Lymphocytes that prevent drying integrity. evidenced by:
produces and secretes of the skin
Immunoglobulins - Inspect the skin for - Early - Patient verbalizes
(antibodies) and pallor, redness and recognition of comfortability,
monocytes Long Term Goal: breakdown. signs of impaired decrease feeling of
/macrophages skin integrity itchiness and
,neutrophils After a week of allows prompt gradual
nursing intervention, intervention. disappearance of
the patient will be rashes.
maintain skin integrity - Implement measures - The outermost
Antibodies attach to the as evidenced by: to reduce friction layers of the skin - Patient’s skin
viral antigens and then between the skin and can be damaged color(pigmentation)
Monocytes/macrophage a. absence of another surface. when dragged becomes normal
s will perform redness and along or rubbed (absence of
phagocytosis irritation against another redness)
 NURSING CARE PLAN
Name: Adrian Eugenio Age: 20 years old Diagnosis: DHF II
Through Fc receptors b. no skin surface.
within the cells and breakdown Reducing friction
dengue helps prevent
Virus replicates in the skin surface
cells irritation.

-Provide skin -To maintain

Recognition of dengue hygiene through skin
viral antigen on infected sponge bathing & integrity at
monocyte changing regularly optimal
and generate cellular level. Keeping
response skin clean
removes many
surface
initiates immune microorganisms,
response which, if allowed
to accumulate,
increase the risk
release of cytokines for irritation or
which consist of infection and
vasoactive agents subsequent skin
such as interlukins, breakdown.
tumor necrosis factors,
urokinase and platelet - Keep bed clothes -To avoid
activating WBCs and dry, use non- lesions,
pyrogen release irritating materials, & scratching of
keep bed wrinkled skin &
free harboring of
release of exogenous Microorganism.
pyrogens
- Palpate skin - To assess
lesions for size, extent
decrease WBC shape, consistency, of involvement of
(neutrophils and texture & hydration skin impairment.
macrophages)
 NURSING CARE PLAN
Name: Adrian Eugenio Age: 20 years old Diagnosis: DHF II
- Encourage -To prevent
reposition schedule friction
Release of edogenous for client that may cause
pyrogens irritation of the
skin
- Implement measures - Dry skin is
Reset of hypothalamic to prevent drying of the more prone to
thermostat skin such as encourage cracking and has
a fluid intake of decreased
2500ml/day and apply elasticity, which
Fever moisturizing lotion at make it
least once a day susceptible to
damage.
Cellular direct and - Provide information - To promote
infection red bone to the client about wellness by
marrow pre cursor cells the importance of gaining
as well as platelet regular observation knowledge on
precursor & effective skin care treatment/
therapy
Collaborative:
Thrombocytopenia
- Notify appropriate - Notifying the
health care provider if appropriate
Coagulation defect skin breakdown occurs. health care
provider allows
modification of
treatment plan.