Please comment on my NCP about DENGUE HEMORRHAGIC FEVER

[Dervid Jungco]

ASSESMENT

11 Year old male pedia patient with Dengue Hemorrhagic Fever rushed in the E.R

SUBJECTIVE :

"Nahihilo po ako, Nauuhaw at nanlalata" as verbalized by the client. [ Means, I AM DIZZY, THIRSY AND I FEEL SO WEAK" ]

OBJECTIVE :

+ Sunken, Dry eyes

+ Pale palpebral conjunctiva

+ Dry lips and mouth

+Prolonged Capillary refill time [ 7 seconds ]

+ Poor skin turgor

+ Rapid, Thready Pulse

Heart rate - 110 Bpm

RR - 21 Bpm

BP - 90/60

Temp - 39.2 C

DIAGNOSIS

Fluid Volume Deficit R/T Intravascular to Extravascular Plasma Leakage Secondary to Increase in Vascular Permeability.

OBJECTIVES

SHORT TERM: After an hour of spontaneous fluid replacement, Patient will gradually abate signs and symptoms of fluid volume deficiency as evidenced by increasing blood pressure, decreasing heart rate, improving capillary refill time preferably below 5s and an improving skin turgor.

{ LONG TERM : After 2 days of nursing intervention, Patient will maintain fluid volume at an amount optimum for normal functioning as evidenced by a normal urine output with normal specific gravity, stable vital signs, moist mucus membrane, good capillary refill time and resolution of third spacing.}

INTERVENTION

1. Anticipate fluid replacement by preparing peripheral route for IV transfusion.

2. Obtain doctor's order for IV therapy As soon as possible to replace fluid volume loss IMMEDIATELY.

3. Encourage fluid intake by placing a glass of juice or water within the patient's reach.

4. Monitor total fluid intake and output every 2 hours.

5. Watch trends in output for 3 days; include all routes of intake and output and note color and specific gravity of urine.

6. Monitor vital signs of clients with deficient fluid volume every hour. Observe for decreased pulse pressure first, then hypotension, tachycardia, decreased pulse volume, and increased or decreased body temperature

RATIONALE

1. IV transfusion is a dependent nursing function. Anticipate doctor's order by providing route for IV fluid replacement to save time and decrease risk for complications.

2. IV is considered as MEDICATION. Before initiating IV Replacement therapy, make sure that there is a current standing or verbal order from the doctor.

3. placing a glass of water or juice at patient's bedside is the best way to encourage fluid intake. DHF patient are always thirsty prior to the defervescence stage.

4. A urine output of .5 ml per kg/hr is insufficient for normal renal function and indicates onset of renal damage

5. Monitoring for trends for 2 to 3 days gives a more valid picture of the client's hydration status than monitoring for a shorter period. Dark-colored urine with increasing specific gravity reflects increased urine concentration.

6. To monitor and assess client's response and progress in the fluid replacement therapy.

EVALUATION

SHORT TERM : After an hour of intervention, Patient's BP increased to 100/70, Tachycardia resolved as evidenced by a normal HR of 80bpm. CRT decreased from 7s down to 4s and there is a noticeable improvement in the client's skin turgor.

{LONG TERM : 2 Days after a series of nursing care, the patient manifested a normal urine output of 30ml per hour with a specific gravity of 1.011. Stable vital signs were monitored and recorded. CRT was recorded normal. Physical assessment revealed no sign of fluid deficit.}

---nothing follows---

Comments , suggestions, reactions?

[Dervid Jungco]

ill bump this up.. thanks

[suzanne4, RN]

Where exactly are you located? I do not think in the US, as we do not normally see that here, unless the patient has just returned froim an overseas trip.

Please tell me where you are located, then I can tell you what else that you need to include, but it will depend on where you are located.

[suzanne4, RN]

With an 11 year old with Dengue, you would expect the heart rate to be much higher, especially with what you are already describing as issues that he is presenting with. Also, the BP that you have is a normal one for someone that is that age, what would you expect to actuslly see? The respiratory rate that have listed is well within the normal rate, what do you think that you would see?

Next, you mention giving the patient fluids, but how are you going to calculate what his bolus is going to be? You will need his weight in kg to be able to do this, and this should be included in any care plan on a child. There are specifics that are used to calculate the amount of fluid that he would initially receive. Then how would you calculate the next fluids to follow?

Skin turgor will not normally improve in just one hour. And the urine output that you have listed is actually a little on the low side, especially if he is bleeding, and you want to keep the urine flowing. What amount would you really like to see? That is more for a normal child.

[Dervid Jungco]

Thank you.... ill improve it using your suggestions.

[Dervid Jungco]

ASSESMENT

11 Year old male pedia patient with Dengue Hemorrhagic Fever

SUBJECTIVE :

“ Ang sakit po ng tiyan ko pati mga tuhod ko at binti” as verbalized by the client. [ My stomach hurts, as well as my knees and legs " ]

OBJECTIVE :

+ Diaphoresis

+ Pupillary dilatation

+ Cold Clammy skin

+Apparent loss of appetite

A documented pain scale of 6 on FPSR Pain scale.

Heart rate – 125 bpm

RR - 34 bpm

DIAGNOSIS

Acute Pain R/T Massive endothelial tissue damage Secondary to pyrogenic dissemination.

OBJECTIVES

SHORT TERM : After 2 hours of nursing interventions, Patient will describe the pain as tolerable with minimal and manageable side effects.

Pain scale using FPSR should range from 0 to 4 and patient should show a decreased sign of pain induced parasympathetic stimulation.

LONG TERM : After 1 day of nursing interventions, Patient should exemplify an acceptable sleep-rest pattern as exhibited by statement of being able to obtain a sufficient amount of rest and sleep as well as an increased appetite manifested by an improved eating pattern.

Patient should also exhibit no signs of pain as documented by a score of 0 on the FPSR scale.

Patient should also manifest no sign and symptom of pain.

INTERVENTION

1. Administer Acetaminophen at minimal dosage as ordered.

2. Carefully monitor patient’s response to the medication by assessing the client

3. Provide a quiet environment conducive to resting and sleep.

4. Provide non pharmacological comfort measures like deep breathing exercises, guided imagery, praying and distractions like story telling and listening to a soothing music.

RATIONALE

* Dengue patients experience hepatomagaly which suggests liver overcompensation that impairs drug metabolism, Acetaminophen should be given at minimal therapeutic dose.

* To detect if the condition is improving or worsening, Or if there is a need to increase the dosage of the medication.

* To promote adequate rest and sleep periods that will prevent fatigue and decrease severity of pain.

* To decrease patient’s perception of pain and increase his tolerance to pain. This will also increase the child’s adaptive pain behaviour.

EVALUATION

SHORT TERM : After 2 hours of nursing interventions, The patient verbalized “Hindi na po masyadong masakit ang katawan ko pati yung mata ko at tuhod” [ I dont feel pain on my body as well as on my eyes and knees anymore " ]

Re assessing FPSR revealed a score of 2. Diaphoresis is not anymore evident. Patient skin is now warm to touch.

LONG TERM : After a day of continuous nursing intervention patient verbalized “Tuloy tuloy naman po ang tulog ko kagabi at kumain na po ako kanina pagka gising ko” [ I slept alright last night, I just ate this morning after I woke up " ]

Re assessing FPSR revealed a score of 0.

Re assessing patient’s vital signs revealed no indication of pain occurrence. Physical assessment suggests no pain related stimulation of the parasympathetic nervous system.

this is my 2nd NCP, all about PAIN... hope you could comment again miss suzanne.

[suzanne4, RN]

Are you doing individual care plans or only focusing on one area?

You should be including both problems in the same care plan, addressing each of the issues, noit completely individual like you are doing here.

Have you ever seen a patient with Dengue? They usually are not even moving much, what other durg would you prefer to use to avoid any issues with what we call Tylenol over here? It also doesn't always work well in kids that are sick with a very high fever. Ibuprofen would be a better choice in this case. Again, with the pain, you also need to include fluids. The pain is usually caused by the dehydration. You must include the wieght of the child and how much drug that you would give him based on his weight.

Your care plan is based on the needs of the one patient, and should incldue all of the areas that need to be focused on. You need to give the subjective and the objective, combine them all together, you have different things listed for each. Then list the problem and go from there.

[Dervid Jungco]

we are required to make INDIVIDUAL NCPS depending on the priority. I read some articles and they dont suggest use of NSAID. THe common pain reliever given is acetaminophen because NSAID like aspirin and ibuprofen are associated with reye's syndrome and can prolong PTT PT that could lead to further bleeding.

I am aware of the tylenol scare there, but it is not widely known here.

we have different ncp format being used here so I am really intrested reading a U.S format NCP. I dont like to get intervention or R/T from books because I want to make my NCP personalized as much as possible.

Again your suggestions are intresting, I will follow it ASAP.. I will put the dosage and fluids as to make my NCP more specific.

[suzanne4, RN]

You usually do not see Reyes Syndrome in a child of that age, and ibuprofen is used here all of the time, even on babies.

I would try other cooling methods first before going to giving the Tylenol Cooling blanket, ice bags to the groins and under the arms, a fan. etc.

[Dervid Jungco]

You usually do not see Reyes Syndrome in a child of that age, and ibuprofen is used here all of the time, even on babies.

I would try other cooling methods first before going to giving the Tylenol Cooling blanket, ice bags to the groins and under the arms, a fan. etc.

TY very much, I am used to giving meds as my first intervention and i was just enlightened by your thoughts to use independent interventions first.

[Czarene]

dervid jungco..

Our Lady of Fatima University Board exam Top Notcher.. ^_^