Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Ineffective Goal: Independent: After 4 hours of
“mainit ang thermoregulation r/t After 4 hours of >monitor v/s, >a DHF patient has a nursing
pakiramdam ko”, as illness (DHF) as nursing intervention, especially temperature fluctuating body intervention, the
verbalized by the manifested by body the patient’s body and RR temperature; a febrile patient’s body
patient temperature above temperature will be patient is usually temp erature was
the normal range maintained within the tachypnic maintained within
Objective: (36.5-37.5) normal range the normal range
Temp: 37.7°C >regulate and monitor >to replace lost fluid
RR: 26cpm Specific Objectives: IV and electrolytes
>skin is warm to touch The patient will…
>flushed skin >verbalize >perform TSB >to lower body
>IV: PLRS 1Lx220cc/hr understanding of temperature
individual factors and
Lab Results: appropriate >encourage an >to prevent
WBC: 5.7x109/L interventions increase in OFI dehydration caused
>demonstrate by fever
techniques to correct
underlying condition >keep linens dry >to keep patient
warm and
comfortable
>provide health >health education
teachings regarding:
- diet
-proper clothing
(warm)
-causes and
prevention of DHF
(CLEAN program)
-meds: do not take
aspirin or any med
that contains aspirin
Dependent: >pharmacologic
Administer antipyretic intervention
meds as ordered by
physician
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Risk for hemorrhage Goal: Independent: After 2 hours of
N/A r/t altered clotting After 2 hours of >Monitor v/s, >sudden drop of BP nursing intervention,
factors as manifested nursing intervention, especially PR and BP along with an the patient was at
Objective: by an APC result the patient will be at increase of PR may lower risk for
(+) Herman’s sign below the normal lower risk for indicate hemorrhage hemorrhage as he
range (150-400) hemorrhage that may lead to verbalized its possible
Lab Results: shock causes and
Platelet: 72 Specific Goals: demonstrated
Hematocrit: 43.44% The patient will… >note changes in LOC >lower level of LOC behaviors that
>verbalize possible may indicate reduced its risk
causes of hemorrhage, thus the
hemorrhage hypoxia
>demonstrate
behaviors that will >encourage adequate >to prevent accidents
reduce risk for rest and lessen body’s
hemorrhage oxygen demand
>assess for s/sx of GI >for monitoring of
bleeding. Check for internal hemorrhage
secretions. Observe
color and consistency
of stools and vomitus
>provide health >for health education
teachings regarding:
-diet: avoid dark-
colored foods; eat
foods rich in vit C
-ADL: avoid straining
for stool and forceful
nose-blowing;
encourage use of
soft-bristle
toothbrush
-meds: do not take
aspirin
Dependent:
>administer >pharmacologic
coagulants if ordered intervention
by physician
Collaborative:
>monitor platelet and >platelet and hct are
Hct levels coagulating fcotrs of
the blood
