St.

Anthony’s College
San Jose, Antique
Nursing Department
NAME: O.J.K
AGE: 5
Dr.: B
Dx: Dengue Fever positive NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Risk for bleeding This infectious After 8 hrs. of nursing INDEPENDENT:
“I have some rashes all related to altered disease is manifested interventions, the client  Advised to increase Oral  To prevent dehydration Goal met.
over my body”, as clotting factor due by a sudden onset of will be able to fluid intake After8˚ of nursing Intervention
verbalized by the to dengue fever, with severe demonstrate behaviors  Advised patient not to  As it may alter the patient was able to demonstrate
patient hemorrhagic fever headache, muscle that reduces the risk for eat dark colored foods. result of the stool behaviour that reduced the risk
and joint bleeding exam in determining if for bleeding
pains(myalgias and there’s presence of
arthralgias—severe blood/ if there’s GI
pain gives it the bleeding.
name breakbone  Assess for signs and  The G.I. tract
fever or bonecrusher symptoms of G.I (esophagus and
OBJECTIVE: bleeding. Check for rectum) is the most
(+) petechae on the Secretions. Observe usual source of
upper torso and arms color and consistency of bleeding of its mucosal
stools or vomitus. Fragility
Irritable  Observe for presence of  Sub-acute
petechiae, bleeding disseminated
from one or more sites intravascular
coagulation(DIC) may
develop secondary to
altered clotting factors.
 Monitor pulse,  An increase in pulse
Blood pressure. with decreased
Blood pressure can
indicate loss of
circulating blood
volume.
  In the presence
 Encouraged to use of of clotting factor
soft toothbrush, disturbances,
avoiding straining for minimal trauma
stool, and forceful nose can cause mucosal
blowing. bleeding
 Minimizes
 Use small needles for damage to tissues,
injections. Apply reducing risk for
pressure to venipuncture bleeding and hematoma
sites for longer than
usual.  Prolongs coagulation,
 Recommend avoidance potentiating risk of
of aspirin containing hemorrhage
products.

COLLABORATIVE:  Indicators of anemia,

 Monitor Hb and active bleeding, or
Hct and clotting Impending
factors. complications.
 St. Anthony’s College
San Jose, Antique
Nursing Department
NAME: G.C
AGE: 9
Dr.: R
Dx: Dengue Fever NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Risk for bleeding This infectious After 8 hrs. of nursing INDEPENDENT:
“ga katul akun lawas”, related to altered disease is manifested interventions, the client  Advised to increase Oral  To prevent dehydration Goal met.
as verbalized by the clotting factor due by a sudden onset of will be able to fluid intake After8˚ of nursing Intervention
patient to dengue fever, with severe demonstrate behaviors  Advised patient not to  As it may alter the patient was able to demonstrate
hemorrhagic fever headache, muscle that reduces the risk for eat dark colored foods. result of the stool behaviour that reduced the risk
and joint bleeding exam in determining if for bleeding
pains(myalgias and there’s presence of
arthralgias—severe blood/ if there’s GI
pain gives it the bleeding.
name breakbone  Assess for signs and  The G.I. tract
OBJECTIVE: fever or bonecrusher symptoms of G.I (esophagus and
(+) petechae on the bleeding. Check for rectum) is the most
upper torso and arms Secretions. Observe usual source of
color and consistency of bleeding of its mucosal
stools or vomitus. Fragility
Restless  Observe for presence of  Sub-acute
petechiae, bleeding disseminated
from one or more sites intravascular
coagulation(DIC) may
develop secondary to
altered clotting factors.
 Monitor pulse,  An increase in pulse
Blood pressure. with decreased
Blood pressure can
indicate loss of
circulating blood
volume.
 Encouraged to use of  In the presence
soft toothbrush, of clotting factor
avoiding straining for disturbances,
stool, and forceful nose minimal trauma
blowing. can cause mucosal
bleeding
 Use small needles for  Minimizes
injections. Apply damage to tissues,
pressure to venipuncture reducing risk for
sites for longer than bleeding and hematoma
usual.
 Recommend avoidance  Prolongs coagulation,
of aspirin containing potentiating risk of
products. hemorrhage

COLLABORATIVE:
 Monitor Hb and  Indicators of anemia,
Hct and clotting active bleeding, or
factors. Impending
complications.