Ncp Dengue

Far Eastern University Institute of Nursing Nursing Care Plan Cues

Observation: -Client appeared irritable. -Client is with fair reflexes. -Client has poor skin turgor assessed at the abdomen. -Client has unsunken eyes and fontanels. -Client has moist skin folds including the antecubital fossa. -Client has dry mucous membranes including the buccal and oral mucosa.

-Client passed out stool once in the morning. Stool was semi-soft, yellow in color and not watery. BP= 120/80 mmHg CR= 90bpm PR= 20cpm

Nursing Diagnosis

Rationale

Goal and Objectives

Deficient fluid volume related to fever, vomiting and excessive perspiration.

Situational Analysis 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 extra cellular fluid volume deficit is the isotonic loss of body fluids, that is, relatively equal losses of sodium and water.

Goal: After an 8-hour shift, client will be able to demonstrate adequate fluid balance as evidenced by good skin turgor, moist skin and mucous membranes; caregiver will be able to verbalize understanding of child’s fluid needs and will be able to demonstrate behaviors to prevent development of fluid volume deficit.

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, thirdspace fluid shift, and a combination of these factors causes 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.

Interventions

Rationale

Goal met. After an 8hour shift, client was able to demonstrate adequate fluid balance as evidenced by good skin turgor, moist skin and mucous membranes; caregiver will be able to verbalize understanding of child’s fluid needs and will be able to demonstrate behaviors to prevent development of fluid volume deficit.

Objectives: Facilitative 1.The causative or precipitating factors that cause the client’s condition & the degree of fluid deficit will be evaluated.

1.Note potential sources of fluid loss/intake. 2.Continue monitor the vital signs, mucous membranes, weight, skin turgor, breath sounds, urinary and gastric output.

Evaluation

1.Causative/contributing factors for fluid imbalances. 2.Indicators of hydration status. Note: Hypotension indicative of developing shock may not be readily observed in pediatric

Objective met.

patients until very late in the clinical course.

Temp: 37.8c. Fluid shift related to burns during the initial phase, vomiting, acute intestinal obstruction, acute gastro enteritis, acute peritonitis, crushing injury, hip or pelvic fracture (1.5 to 2 L of blood may accumulate in tissues around the fracture), pancreatitis and pleural effusion may also contribute to fluid volume deficit. Another possible causes of reduced fluid volume are dysphagia, coma, environmental conditions preventing fluid intake and psychiatric illness. Health Implication Hypovolemia is an isotonic disorder. Fluid volume deficit decreases capillary hydrostatic pressure and fluid transport. Cells are deprived of normal nutrients that serve as substrates for energy production, metabolism, and other cellular functions. Decreased renal blood flow triggers the rennin-angiotensin system to increase sodium-water reabsorption. The cardiovascular system compensates by increasing heart rate, cardiac contractility, venous constriction, and systemic vascular resistance, thus increasing

4.Review patient’s intake of fluids. Hydrate with water after every feeding.

4.Provides baseline and comparison

5.Determine child’s normal pattern of elimination.

5.Provides information for baseline and comparison.

6. Continue monitor the patient’s weight and compare the result on the next days. Weigh on the same scale at the same time of day & wearing same amount of clothing

6. Consistency with weight measurement helps ensure more accurate results. Weight is a useful indicator of fluid balance. Weight loss indicates that child is not receiving adequate fluid replacement and adjustments need to be made.

Supplemental 1.Administer and monitor IV fluids as ordered.

2.After 30 minutes of nursing care, the client will be able to elicit no signs of dehydration.

2.Request for laboratory results, e.g., hemoglobin/hematocrit (Hb/Hct), BUN, urine osmolality/specific gravity. Developmental 1. Instuct the caregiver to apply moist towel on client’s lips when noted dry. Facilitative

1. Provides fluid & nutritional support to replace active fluid loss.Close monitoring and regulation is required to prevent fluid overload while correcting fluid balance. 2.Indicators of adequacy of hydration/therapeutic interventions.

1. Moist towel may reduce the dryness of the oral musosa.

cardiac output and mean arterial pressure. It also triggers the thirst response, releasing more antidiuretic hormone and producing more aldosterone. When compensation fails, hypovolemic shock occurs in the following sequence: -decreased intravascular fluid volume -diminished venous return, which reduces preload and stroke volume

1. Provide fresh water and oral fluids preferred by the client (distribute over 24 hours) provide prescribed diet; offer snacks. Instruct significant other to assist the client with feedings as appropriate. 2. After 15 minutes of nursing intervention, client will be able to feed with ease and without undue discomfort.

1. Provide frequent oral hygiene, at least twice a day

-decreased mean arterial pressure -impaired tissue perfusion

2. Provide comfort measures (e.g. clean cloth, clean linens, etc.)

-decreased oxygen and nutrient delivery to cells,

Possible complications of hypovolemia include shock and acute renal failure. (Lippincott Manual of Nursing Practice Series Pathophysiology; 2007; pp.458-461)

Objective met.

2.Provides information about digestion/bowel function and may affect choice/timing of feeding.

Facilitative

-reduced cardiac output

-multiple organ dysfunction syndrome

2.Auscultate bowel sounds. Note characteristics of stool (color, amount, frequency, and so on).

1. The oral route is preferred for maintaining fluid balance Distributing the intake over the entire 24-hour period and providing snacks and preferred beverages increases the likelihood that the client will maintain the prescribed oral intake.

3. After 15 minutes of nursing intervention, client will be able to comfortable and manifest no signs of irritability and will be able to rest comfortably.

1. Oral hygiene decreases unpleasant tastes in the mouth and allows the client to respond to the sensation of thirst.

3.Provide a quiet environment. 2. Promotes comfort level & distraction. Developmental 1.Educate caregiver factors contributing to dehydration, complications of dehydration, signs of dehydration and different ways in preventing dehydration.

3.Quiet environment promotes good rest and comfort. 1.Ensures continued preventive measures in home setting. (Pediatric Nursing Care Plans; Swaeringer; 2006; pp.674-676)

Objective met.

(Fundamentals of Nursing; Taylor et. al.; 5th Edition; 2005)

4. After 20 minutes of nursing action,patient will be able to enumerate at least 3 out 5 infant care measures of preventing dehydration.

Cues Subjective: “Isang araw parang dumugo ilong ko pero konting konti palang naman”as verbalized by the Patient. Objective: · Weakness and irritability. · Restlessness. · V/S taken as follows: BP= 120/80 mmHg CR= 90bpm PR= 20cpm Temp: 37.8c.

Nursing diagnosis Risk for Bleeding related to altered clotting factor.

Rationale This infectious disease is manifested by a sudden onset of fever, with severe headache, muscle and joint pains (myalgias and arthralgias— severe pain gives it the name breakbone fever or bonecrusher disease) and rashes and usually appears first on the lower limbs and the chest. There may also be gastritis and some times bleeding.

Goals & Objectives After 8 hrs. Of nursing interventions, the client will be at reduced risk for bleeding

Objectives: 1.After 3 hours of nursing intervention the patient will be able to identify factors that could increase risk of bleeding.

Objective met.

Intervention

Rationale

Evaluation Goal met. After 1 hr. Of nursing interventions, the client was able to demonstrate behaviors that reduce the risk for bleeding.

Independent: · Assess for signs and symptoms of G.I bleeding. Check for secretions. Observe color and consistency of stools or vomitus.

The G.I tract (esophagus and rectum) is the most usual source of bleeding of its mucosal fragility.

Objective met.

· Sub-acute

· Observe for presence of petechiae, ecchymosis, bleeding from one more sites.

disseminated intravascular coagulation (DIC) may develop secondary to altered clotting factors.

· Monitor pulse, Blood pressure.

· An increase in pulse with decreased Blood pressure can indicate loss of circulating blood volume. · Changes may indicate cerebral perfusion secondary to hypovolemia, hypoxemia. · Rectal and esophageal vessels are most vulnerable to rupture.

· Note changes in mentation and level of consciousness.

2.After 3 hours of Nursing intervention, the patient will be able to demonstrate ways to reduce risk for bleeding.

· Avoid rectal temperature, be gentle with GI tube insertions. · Encourage use of soft toothbrush, avoiding straining for stool, and forceful nose blowing. · Use small needles for injections. Apply pressure to venipuncture sites for longer than usual. · Recommend

· In the presence of clotting factor disturbances, minimal trauma can cause mucosal bleeding. · Minimizes damage to tissues, reducing risk for bleeding and hematoma.

Objective met

avoidance of aspirin containing products. Collaborative: · Monitor Hb and Hct and clotting factors.

Cues Subjective: Complaining for (+) pain in her IV insertion site and arms.. “Ang sakit sakit niya siguro dahil sa gamut o kaya baka wala na sa linya ung IV,” as verbalized by the patient. A pain scale of 5/10 Objective: Grimacing upon touching of arm Tender to touch and warm. With slight inflammation.

BP= 120/80 mmHg CR= 90bpm PR= 20cpm Temp: 37.8c.

Nursing diagnosis Acute Pain related to IV medication/side drip of KCL

Analysis Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage ; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than six months. Acute pain, which usually occurs in response to tissue injury, results from activation of peripheral pain receptors and their specific A delta and C sensory nerve fibers (nociceptors). Pain fibers enter the spinal cord at the dorsal root ganglia and synapse in the dorsal horn. From there, fibers cross to the other side and travel up the lateral columns to the thalamus and then to the

· Prolongs coagulation, potentiating risk of hemorrhage. · Indicators of anemia, active bleeding, or impending complications

Goals and objective GOAL: After 2 hours of student nurses’ intervention the patient’s pain scale will be reduced by two while on KCL side drip

Nursing interventions

OBJECTIVES: After 30 minutes of assessment with the patient, the patient will be able to identify at least ways of pain reduction.

Facilitative: Assess nature and degree of discomfort.

Rationale

These data provide information about the subjective experience of discomfort for this client.

Assess blood pressure and pulse and IV site.

Provides baseline and comparison

Supplemental and Developmental: Assist with measures that reduce discomfort. These include: • Discussion and

Reduces discomforts.

Evaluation Goal met. The client was able to experienced gradual reduction or relief of pain as evidenced by decreased pain scale from 5/10 to 2/10, having normal BP and PR, and verbalization of reduction of pain. The client was also able to identify 1 cause of pain, and choose and apply one way to alleviate pain.

cerebral cortex.

demonstration to the client breathing relaxation techniques and encouraging use of breathing/relax ation techniques.

Repetitive stimulation (eg, from a prolonged painful condition) can sensitize neurons in the dorsal horn of the spinal cord so that a lesser peripheral stimulus causes pain (wind-up phenomenon). Peripheral nerves and nerves at other levels of the CNS may also be sensitized, producing long-term synaptic changes in cortical receptive fields (remodeling) that maintain exaggerated pain perception. Substances released when tissue is injured, including those involved in the inflammatory cascade, can sensitize peripheral nociceptors. These substances include vasoactive peptides (eg, calcitonin gene-related protein, substance P, neurokinin A) and other mediators (eg, prostaglandin E2, serotonin, bradykinin, epinephrine).

After 2 ½ hours of discussion and demonstration to the patient, the patient will be able to apply

•

Warm to cold compress

Ice provides local anesthesia, promotes vasoconstriction, and reduces edema formation

•

Reduction of stimulation in the environment

Pain may be associated with anxiety; blood pressure and pulse are elevated with anxiety.

•

Provision of arm rubs

Divert pain to other stimulation/sensation. Provides relaxation.

•

Teach Diversional activities like sleeping, talking with company, reading books.

Forget about the feeling of pain by focusing on other activities

Facilitative: Institute comfort measures -Warm to cold Compress - Slight Arm rubs

Promotes comfort

at least one way to alleviate pain

After 3 hours of intervention the client will be able to verbalize improved comfortability.

Collaborative Administer analgesic as needed. Assess effectiveness of pain medication. Explain action of analgesic, time factors and restrictions.

Analgesics act on higher brain centers to reduce perception of pain, promoting relaxation, facilitating rest and sense of well-being. Knowledge of typical effect aids in developing realistic expectations. Knowledge of time restrictions, with reasons, allows client compliance with orders.