ASSESMENT NURSING ANALYSIS/ GOALS/ EXPECTED NURSING INTERVENTIONS SCIENTIFIC EVALUATION

DIAGNOSIS PATHOLOGY OUTCOMES RATIONALE

Subjective Fluid Volume In Dengue  Assess patient’s  To serve as Goal met.

Deficit fever, there is The patient will physical appearance. baseline
“Nangayayat siya,” as R/T: Active fluid an increased display no signs of data.
verbalized by the loss permeability dehydration after 24 The patient
 Monitor patient’s
patient’s mother. AEB: dry skin of the blood hours. vital signs.  To serve as displayed no
and dry mouth, vessels baseline signs of
Objective decreased urine resulting to data. dehydration
output, extravasation 
weakness. that leads to
Advise patient’s within 24
mother to increase  To replace
dehydration fluid loss. hours.
 Weak in fluid intake of pt.
which
appearance affected the
patient as
 Dry skin evidenced by
having dry
 Dry mouth
skin and
 Decreased mouth.

urine output
 Drug Action Indication Contraindications Interactions Adverse Effect Nursing
Name Consideration
Reduces fever Temporary reduction  Contraindicate Drug-drug: CNS:Headache  Observe the
by acting directly of fever d with allergy  Increased CV: Chest pain, 10 rights of
Generic Name: on the to paracetamol. toxicity with dyspnea, myocardial administerin
long term, g
PARACETAMOL hypothalamic damage
 Use cautiously excessive paracetamol
heat regulating GI: Hepatic toxicity &
with impaired ethanol .
center to cause failure, jaundice, Assessment
hepatic ingestion.
vasodilation and function,  Increased GU: Acute renal  History –
Brand Name: sweating which chronic hypoprothro failure, renal tubular allergy to
----------------- helps dissipate alcoholism, mbinemic necrosis paracetamol
heat regulating pregnancy and effect of Hematologic:  Physical –
center to cause lactation. anticoagulant Methemoglobinemia skin color,
. lesions
Classification: vasodilation and cyanosis hemolytic
 Increased risk Intervention
Antipyretic, sweating which of anemia- hematuria,
 Tell parents
analgesic helps dissipate hepatotoxciti anuria, neutropenia, to consult
heat. y and leucopenia, prescriberbe
Dosage: possible pancytopenia, fore giving
100mg/mL decreased thrombocytopenia, drug to
every 4 hours if therapeutic hupoglycemia children
effect with younger
temp is greater Other:
biturates, than age 2.
than or equal to carbamazepi Hypersensitivity,
 Tell patient
37.8 degrees ne, rash, fever not to use for
Celsius hydantoins, marked fever
rifampin, ( temp higher
sulfmpyrazon than 103.1
degrees
e.
Fahrenheit or
 Possible 39.5 degrees
delayed or Celsius) Fever
decreased persisting
effectiveness longer than 3
with days, or
anticholinergi recurrent
cs. fever.
.
 ASSESMENT NURSING ANALYSIS/ GOALS/ EXPECTED NURSING INTERVENTIONS SCIENTIFIC EVALUATION
DIAGNOSIS PATHOLOGY OUTCOMES RATIONALE

Subjective Risk for Due to  Assess patient’s  To serve as Goal met.

Infection inadequate The patient will physical appearance baseline
primary display no signs of particularly the skin. data.
defenses(skin infection within his  To serve as The patient did
 Note the signs of
R/T: ) as evidenced stay in the hospital. baseline not display
“Kamot siya ng kamot infection through
Inadequate by petechial monitoring the vital data. signs of
nung rashes niya,” as primary rashes on the signs.  To reduce infection while
verbalized by the upper and  Provide a clean risk of
defenses in the hospital.
patient’s mother. lower environment. infection.
extremities  Encourage patient’s  To reduce
AEB: Petechial and dry risk of
Objective mother to promote
rashes on the wound on the infection.
proper hygiene of
upper and lower lid, the patient.
lower patient is at
extremities and risk of having
 With dry wound on infection due
petechial the left lower to his
rashes on the frequent
lid
upper and scratching of
skin brought
lower by the
extremities itchiness.
 With dry
wound on
the left lower
lid
ASSESMENT NURSING ANALYSIS/ GOALS/ EXPECTED NURSING INTERVENTIONS SCIENTIFIC EVALUATION
DIAGNOSIS PATHOLOGY OUTCOMES RATIONALE
Subjective Acute Pain Due to health  Monitor sleeping  To evaluate Goal met.
interventions The patient will pattern and client’s
R/T: physical applied to the have a good sleep frequency of sighing; response to
patient such and decreased nursing The patient
crying of patient
injuring agents as insertion of frequency of crying/ intervention. displayed good
“Madalas siyang  Use puppets in
IV catether, sighing within 24 demonstrating  To enhance sleep and
umiyak, kahit AEB: Protective the skin gets hours. procedures for the understandi decreased
madaling araw,” as behaviour, damaged child ng and
frequency of
verbalized by the sleep hence, pain  Suggest that parent reduce level
disturbance, receptors in be present during of crying &
patient’s mother. the skin are anxiety/fear. sighing within
restlessness, procedures.
sighing, crying stimulated by  Provide a calm  To promote 24 hours.
Objective the injury. environment. comfort to
always.
Release of the child.
various  To promote
chemicals by comfort to
 Protective the damaged the child.
cells including
behaviour
histamine,
 Sleep substance P,
disturbance serotonin
 Restlessness (5HT),
 Sighing bradykinin
Crying and
always prostaglandin
s produce
pain to the
affected area.