By: Cazze Lynn Sunio BSN 2B Name of Patient : R.C. Age/Sex : 20/Female Rm. Bed # : DR4-3 Reason For Admission: Fever and Rashes Attending Physicians: Dr. Garado, Dr. Arao, Dr. Nazareno Diagnosis: G-1, AOG: 29 1/7 Date and Time: August 20, 2014 @ 9 am
CUES: Subjective: Miss paki-tawag daw si Doc. Akung kugmo lagi kay puro dugo.
Objective: withCC of fever and rashes. With associate headache andjoint pain.
With pink palpebral conjunctiva. With (+) loss of appetite. With observed weakness / restlessness With observed flushing of face, cheeks and lips. With hemoglobin count of 104 (normal: 120- 160) With WBC count of 18.1 (normal: 5.0-10.0) With platelet count of 17 With (+) Uterine contractions every 15 mins. With VS of: T=35.8 degree celcius CR=107 bpm PR=100 bpm RR=33 bpm BP=90/70 mmhg FHT=126 bpm
Need: Health Perception-Health Management Pattern
Nursing Diagnosis: Injury, risk for bleeding r/t altered clotting factor aeb decreased platelet and hemoglobin count secondary to dengue hemmorhagic fever. R: this disease is manifested by a sudden onset of fever, headache, joint/muscle pain, nausea and vommiting and decreased in appetite. Rashes and ecchymosis can be seen in the acute phase. There may also be gastritis and bleeding because of altered clotting factors due to low platelet count (thrombocypenia) that may lead to worsening cases of DHF. Objective of Care: After 6 hrs. of nursing interventions, the pt. will be able to demonstrate behaviors that reduces the risk for bleeding aeb: a. Gaining good appetite b. Increase in fluid intake c. Avoidane of dark colored foods/fluids and eating food rich in vit. C d. Eradication of weakness/restlessness Nursing Interventions: 1. Establish rapport and good working condition with the patient. R: to gain patients trust and cooperation. 2. Assess for signs and symptoms of G.I. bleeding /nosebleeding. Note for color of stool, vomitus and urine. R: the G.I. track (esophagus & rectum) is the most usual source of bleeding due to its mucosal fragility.
3. Observe for presence of petechiae, ecchymosis, bleeding from one or more sites. R: Sub-acute disseminated intravascular coagulation (DIC) may develop sec. to altered clotting factors. 4. Monitor VS especially Pulse and BP. R: an increase in pulse with decreased blood pressure can indicate loss of circulating blood volume.
5. Encourage use of soft toothbrush, avoid straining for stool, and forceful nose blowing. R: in the presence of clotting factor disturbances, minimal trauma can cause mucosal bleeding. 6. Avoid dark colored foods/fluids. R: dark colored foods/fluids may mask bleeding. 7. Encourage patient to eat food rich in vit. C. R: to boost body resistance to infections that may lead to further complications.
8. Encourage the patient to rest more. R: rest promotes body recovery from aches and pains. 9. Increase in fluid intake as indicated. R: body needs 3- 3.5L of water daily as the body has sensible & insensible water losses. More water intake surely aids in the recovery of the patient and prevents dehydration. 10. Monitor Hb, Hct, WBC and platelet count every 12 hrs. R: These are indicators of anemia, active bleeding/impending complications. Evaluation: August 20, 2014@3pm. Goal partially met. After 6 hrs. of nursing interventions, the patient was able to demonstrate behavior that reduced the risk for bleeding aeb: a. The patient was still observed to have loss of appetite. b. The patients total fluid intake @ the end of the shift is 1,260 cc c. The patient only eats rice & soup, only drinks water and apple juice. d. The patient was able to rest/sleep.