Need help with my nursing diagnosis for dengue

[danes1028]

Wasn't sure with my r/ts.. are these correct?

1)Elevated body temperature related to immune response activation secondary to dengue infection as evidenced by a temperature of 38.9C, flushed skin and warm to touch

2) Acute pain related to immune response activation secondary to dengue virus infection process as evidenced by facial grimace, verbal report of pain and pain scale of 7/10

3) Bleeding related to altered clotting factor as evidenced by a low platelet count of 72 (L)

[LadyFree28, BSN, LPN, RN]

The first and the third "nursing diagnoses" are NOT nursing diagnoses.

Do you have a care plan book?

Tell us more about the patient; what did your assessment that you performed find?

[Here.I.Stand, BSN, RN]

Dengue fever doesn't get nursing dx; the patient gets nursing dx. Can you tell us about the pt's head-to-toe?

[Rose_Queen, BSN, MSN, RN]

Nursing diagnoses come from the patient assessment, not the medical diagnosis. What did you note on your patient's physical assessment that you performed? This is the information that will lead to nursing diagnoses for you patient, not the fact that he/she has dengue fever.

[Libby1987]

Nursing dx's don't have to begin with Impaired/Altered/Potential?

[danes1028]

I'm using Nurse's Pocket Guide for diagnoses and interventions. Pt had one episode of epistaxis when I handled her. Would that be risk for bleeding or bleeding since the problem exists already? Or would these be more appropriate.. risk for ineffective breathing pattern or ineffective airway clearance, risk for aspiration

These were the focus problems.. +vomiting, +abdominal pain, +headache

History of Present Illness: 2 days PTC, patient had intermittent fever (38.7 C). She took bioflu, temporarily relieving fever. No other sign and symptoms noted.

1 day PTC, consult at OPD was done, CBC revealed platelet of 178 and WBC count of 4.41. She was given paracetamol 500mg every 6 hours. UA also revealed WBC of 0.5 and occasional epithelial cells. Complained of headache and general body weakness.

Few hours PTC, consult at OPD was due revealing 138 platelet and 2.52 CBC, with episodes of fever and 1 episode of epistaxis upon sneezing, hence consult and subsequent admission.

Temperature: 38.9 C

Pulse rate: 90

Respiratory rate: 21

Blood pressure: 90/60

Capillary refill time:

SKIN: *(+) flushed skin, *(+)rashes on both lower extremities

EYES: pink palpebral conjunctiva, anicteric sclera

CHEST: symmetrical chest expansion, (-) wheeze, (-) crackles

HEART: adynamic precordium, (-) murmur

ABDOMEN: flabby, normoactive bowel sounds, * (+) tenderness over epigastric and left lumbar area

EXTREMITIES: (-) edema

NEUROGICAL: GCS 15

[Libby1987]

Work your way backwards..

What does she need from you the nurse, what type of nursing care are you providing?

Problem: Does she need fluids? Why? Based on what symptoms or functional problems?

Intervention: How will you give/ensure adequate hydration? How will you measure/assess her hydration status?

Goal: What outcome will indicate she is adequately hydrated.

Determine what she needs from her nursing staff and then put it in the proper verbiage. Coming at it from what you'll actually be doing and why will help keep you within nursing scope.

Pain might be: Altered comfort due to inflammatory process related to infection (not sure if you can use infection in school)

[danes1028]

Thank you all for the input! Yes I did formulate the diagnoses based on my assessment. My mistake for not including the history, assessment, course in the ward etc. and just asked for the diagnoses right away lol. This was a 30+ page case study that was presented in front of a panel.