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NCP

This nursing care plan addresses a patient with dengue fever. The plan includes assessments of increased temperature, sweating, dry lips and a flushed skin, indicating hyperthermia. Interventions are focused on monitoring temperature, providing tepid baths and antipyretics to reduce fever. The plan also notes the patient's decreased appetite and weakness. Assessments include weight, appetite and nutrition history. Interventions encourage appealing foods and avoiding those causing intolerance to improve nutrition and maintain weight. The goals of reducing fever and maintaining appropriate weight and nutrition were both met after nursing interventions.

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Naidin Catherine De Guzman-Alcala
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739 views2 pages

NCP

This nursing care plan addresses a patient with dengue fever. The plan includes assessments of increased temperature, sweating, dry lips and a flushed skin, indicating hyperthermia. Interventions are focused on monitoring temperature, providing tepid baths and antipyretics to reduce fever. The plan also notes the patient's decreased appetite and weakness. Assessments include weight, appetite and nutrition history. Interventions encourage appealing foods and avoiding those causing intolerance to improve nutrition and maintain weight. The goals of reducing fever and maintaining appropriate weight and nutrition were both met after nursing interventions.

Uploaded by

Naidin Catherine De Guzman-Alcala
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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X.

NURSING CARE PLAN


ASSESSMENT
NURSING
DIAGNOSIS
RATIONALE PLANNING NURSING INTERVETION RATIONALE EVALUATION
Subjective:
Kahapon pa
siya may
lagnat as
verbalized by
the patients
mother.

Objective:
Increased
Body
Temp:37.9
Profuse
sweating
Dry lips and
mucous
membranes
Flushed skin
Warm to
touch
Hyperthermia
related to
direct effect
of circulating
endotoxins on
the
hypothalamus
altering
temperature
regulation.
Dengue Fever


Elevated
WBCs


Release of
endotoxins,
that cause
disruption
of
hypothalamic
set point.


Increase in
body
temperature
After 8 hours of
nursing
intervention, the
patient will
demonstrate a
temperature
within the
normal range,
free of chills and
associated
complications.
Monitor patient
temperature (degree and
pattern) and note shaking
chills or profuse
diaphoresis.

Monitor environmental
temperature; limit or add
bed linens as indicated.



Provide tepid sponge
baths; avoid use of
alcohol.


Administer antipyretics
like paracetamol
(biogesic).

Provide cooling blanket.






Temperature of 38.9 -
41.1 C suggests acute
infectious diseases
process. Fever pattern
may aid in diagnosis.


Room temperature or
number of blankets
should be altered to
maintain near normal
temperature.

May help reduce
fever. Use of alcohol
may cause chills,
actually elevating
temperature.

Used to reduce fever
by its central action on
the hypothalamus.


Used to reduce fever
usually greater than
40C when seizures can
occur

Goal is met, after
8 hours of nursing
intervention, the
patient achieved a
temperature
within the normal
range as
evidenced by a
decreased in body
temperature from
37.9 C to 36 C
Patient was also
free of chills and
associated
complications.

X. NURSING CARE PLAN

ASSESSMENT
NURSING
DIAGNOSIS
RATIONALE PLANNING NURSING INTERVETION RATIONALE EVALUATION
Subjective:
Ayaw kumain
ng anak ko as
verbalized by
the patients
mother.

Objective:
Decreased
tolerance for
activity
Weakness
Loss of
muscle tone.
Weight upon
admission in
kilograms:28
Imbalanced
Nutrition: less
than body
requirement
related to loss
of appetite
secondary to
dengue virus.
Dengue Fever


Joint pain


Nausea/
Vomiting


Anorexia




Decrease
appetite
After 3 days of
nursing
intervention,
patient will
demonstrate
stable weight
and will be free
of signs of
malnutrition.
Patient or
mother will
demonstrate
behaviors or
lifestyle changes
to maintain
appropriate
weight.
Independent:

Assess
causative/contributing
factor:

Assess client's weight,
age, strength, activity/rest
level, and so forth

Assess nutritional
history, including food
preferences

Observe and record
patients food intake



Encourage client to
choose food that are
appealing to increase
appetite

Avoid foods that cause
intolerance, increase
gastric motility that
results in epigastric pain
blanket.








Provides comparative
baseline


Identify deficiencies,
suggests possible
interventions

To monitor caloric
intake or insufficient
quality of food
consumption

Children eat a lot of
food that are appealing
to their taste


Foods such as gas-
forming, spicy, too
hot, too cold,
caffeinated beverages
can result to epigastric
pain that will decrease
appetite leading to
weight loss
Goal is met, after
3 days of nursing
intervention,
patient
demonstrated
stable weight and
is free of signs of
malnutrition.
Patients mother
also verbalized
and demonstrated
behaviors and
lifestyle changes
to maintain
patients
appropriate
weight.

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