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San Beda College College of Nursing Mendiola, Manila

This document summarizes a nursing assessment and care plan for a patient diagnosed with dengue fever. [1] The patient presented with signs of dehydration including dry cracked lips and vomiting twice. [2] The nursing diagnosis was risk for deficient fluid volume related to inadequate fluid intake as evidenced by dry mucous membranes. [3] The care plan focused on increasing the patient's oral fluid intake to correct dehydration and prevent complications through education, encouraging fluid consumption, and regulating intravenous fluids as needed.

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Sol Gregorio
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123 views3 pages

San Beda College College of Nursing Mendiola, Manila

This document summarizes a nursing assessment and care plan for a patient diagnosed with dengue fever. [1] The patient presented with signs of dehydration including dry cracked lips and vomiting twice. [2] The nursing diagnosis was risk for deficient fluid volume related to inadequate fluid intake as evidenced by dry mucous membranes. [3] The care plan focused on increasing the patient's oral fluid intake to correct dehydration and prevent complications through education, encouraging fluid consumption, and regulating intravenous fluids as needed.

Uploaded by

Sol Gregorio
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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San Beda College College of Nursing Mendiola, Manila

Patient: R.U. Case: Dengue DCN Assessment: Cues and Clues Signs and Symptoms Su )e$ti(e Cues: ayaw niyang uminom ng tubig as verbalized by the mother & )e$ti(e Cues: -dry cracked lips -vomits 2x -irritable -decreased skin turgor Platelet:6 !P: " #6 $emp: %& P': (%) '': %* Nursing Diagnosis (Pro lem ! "tiology# 'isk +or de+icient +luid volume related to inade,uate +luid intake as mani+ested by dry mucous membranes secondary to dengue +ever S$ienti%i$ Rationale Client &ut$ome Planning Nursing Implementations' Inter(entions Rationale Group: 11 III"(aluation

-luid volume de+icit or hypovolemia occurs +rom a loss o+ body +luid. the shi+t o+ +luids into the third space or +rom a reduced +luid intake/ $he therapeutic goal is to treat the underlying disorder and return the extracellular +luid compartment to normal/ $reatment consists o+ restoring +luid volume and

S*ort +erm: 0+ter (hour o+ nursing interventions. the client will be able to: -1nderstand and verbalize the importance o+ hydration -2emonstrate techni,ues and behaviors that could help in preventing dehydration such as increase oral +luid intake/

IND"P"ND"N+: -3stablish rapport

S*ort term: -$o +acilitate cooperation as well as to gain pt6s trust - $o identi+y early signs o+ dehydration 0+ter (hour o+ nursing interventions. the client was able to: -1nderstand and verbalize the importance o+ hydration -2emonstrate techni,ues and behaviors that could help in preventing dehydration

-0ssess skin turgor and mucous membranes +or signs o+ dehydration -4onitor and document vital signs -0ssess skin color and amount o+ urine/ 'eport urine output less than % ml#hr +or 2 consecutive hours/ -5denti+y the patient6s +luid pre+erences:

- $o have a baseline data -7oncentrated urine denotes +luid de+icit

correcting any electrolyte imbalances/ 'esource: Nursing Care Plans (Nursing Diagnosis and inter(ention ,t* "d# -y: Gula$.'/yers pp. 01-01

type. temperature 8hot or cold9/

-3ncourage the patient to increase +luid intake/ a/ Place +luids at bedside within easy reach/ b/ Provide +resh water and straw/ c/ !e creative in selecting +luid sources e/g/ +lavored gelatin. +rozen :uice bars. sports drink/ 2"A3+2 +"AC2INGS: -describe and teach patient the causes o+ +luid losses or decreased +luid intake -instruct client#;< how to measure and record 5#< -encourage regular oral intake

-;electing those +luids that the patient en:oys drinking can +acilitate replacement therapy/ -5ncrease +luid intake prevents dehydration and maximizes circulation thus promotes a better and stable temperature/

such as increase oral +luid intake

-5n+ormation is the key to managing the problem

-maintain 20$ # 327- diet as needed -proper hygiene and clean environment D"P"ND"N+: -'egulate 5= rate as re,uested by actual doctor6s order/ -$o ensure that ade,uate amount o+ parenteral +luid would be taken by the patient/

Su mitted y: /arisolle Gra$e S. Gregorio /e)ia RN

Su mitted to: /rs. "mma

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