Case Presentation

NURSING CARE PLAN

STUDENT’S NAME: Louanne Tracy B. Cruz

PATIENT’S NAME: R.F. AGE: 13 GENDER: M CIVIL STATUS: S
ADMISSION DATE: 11-22-12 WARD: Palacol 3 ROOM NO.: BED NO.: 15

MEDICAL DIAGNOSIS: Dengue Fever

NURSING DIAGNOSIS: Ineffective tissue perfusion related to decreased HgB concentration in the blood secondary to Dengue fever

SHORT-TERM GOAL: After8 hours of nursing intervention, the client will demonstrate behaviour to improve circulation.

LONG-TERM GOAL: After 4 days of NI, the client will demonstrate increased perfusion as appropriate.

CUES PROBLEM/NURSING DIAGNOSIS SCIENTIFIC REASON GOAL
DESIRED OUTCOME
(Objectives) NURSING INTERVENTIONS
RATIONALE
EVALUATION
STANDARDS CRITERIA

Subjective Cues:

(none)

Objective Cues:

(+) Dengue Rapid Test IgM
Diaphoresis
Palmar Pallor

Ineffective tissue perfusion related to decreased HgB concentration in the blood secondary to Dengue fever

Dengue fever ususally results in abrupt onset of high fever, headache, myalgias, arthralgias, and lymphadenopathy, followed by a rash that appears with a 2nd temperature rise after an afebrile period. Dengue can also cause potentially fatal hemorrhagic fever with bleeding tendency and shock.

Reference: Merck Manual Short-term goal:
After8 hours of nursing intervention, the client will demonstrate behaviour to improve circulation.

Long-term goal:
After 4 days of NI, the client will demonstrate increased perfusion as appropriate.

Independent:
Monitor Vital Signs
Assess patient’s condition
Determine presence ofdysrhythmias
Note presence of bleeding
Elevate HOB
Encourage quiet & restful atmosphere
Instruct to avoid tiring activities
Encourage light ambulation
Encourage use of relaxation techniques
Dependent:
Administer medications as prescribed. The client shall have demonstrated behaviours to improve circulation.
The client