2 Dengue Hemorrhagic Fever Nursing Care Plans

(none)

Objective:

Decreased WBC

Decreased platelet

Decreased HgB

Decreased capillary refill time

Dysrhythmias

Altered LOC

Fever

Chills

Diaphoresis

After 4 hours of NI, the pt will demonstrate behaviours to improve circulation.

Long Term:

After 4 days of NI, the pt will demonstrate increased perfusion as appropriate

Monitor Vital Signs

Assess patient’s condition

Note customary baseline data

Determine presence of dysrhythmias

Perform blanch test

Check for Homan’s sign

Note presence of bleeding

Elevate HOB

Encourage quiet & restful atmosphere

Instruct to avoid tiring activities

Encourage light ambulation

Encourage use of relaxation techniques

Administer medications

To obtain baseline data

To assess contributing factors

For comparison with current findings

To identify alterations from normal

To identify / determine adequate perfusion

To determine presence of thrombus formation

To determine risk of anemia

To promote circulation

To promote comfort & decrease tissue O₂ demand

To decrease cardiac workload

To enhance venous return

To decrease tension and anxiety level

To treat underlying cause

The pt shall have demonstrated increased perfusion as appropriate

O>

> Temp of 39.8

> Flushed skin

> Skin warm to touch

> Chills

The pt. May manifest

> Increased RR

> Tachycardia

> Convulsions

> Sweating

After 4 hours of NI, pt’s temperature will decrease from 39.8 to 37.

Long Term:

After 3 days of NI, the pt will identify underlying factors & importance of treatment as well as s/sx requiring further evaluation or intervention

Monitor Vital Signs

Assess neurologic response, note LOC & orientation, reaction to stimuli, papillary reactions & presence of seizures

Note presence / absence of sweating

Wrap extremities with bath towels

Provide TSB q 15 minutes

Apply local ice packs in axilla

Instruct client to have bed rest

Instruct client to increase OFI

Administer replacement fluids

Administer antipyretics

Reassess temperature q 15 minutes

To obtain baseline data

To evaluate effects & extent of hyperthermia

To monitor heat & fluid loss

To minimize shivering

To reduce body temperature

To reduce body temperature in areas of high blood flow

To reduce metabolic demands / oxygen consumption

To prevent dehydration

To support circulating blood volume and tissue perfusion

To restore normal body temperature

To determine effectiveness of interventions done

The pt shall have identified underlying factors and importance of treatment as well as s/sx requiring further evaluation or intervention