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Assessment Diagnosis Analysis Goals and Intervention Rationale Evaluation

Objectives

SUBJECTIVE : Fluid Volume OBJECTIVES 1. Anticipate 1. IV SHORT TERM :

Deficit R/T Decreased fluid transfusion is After an hour
“Nahihilo po Intravascular intravascular, SHORT TERM: replacement a dependent of
ako, Nauuhaw to interstitial, nursing intervention,
After an hour by preparing
at nanlalata” Extravascular and/or function. Patient’s BP
as verbalized Plasma of peripheral Anticipate increased to
intracellular
by the client. [ Leakage fluid. This spontaneous route for IV doctor’s order 100/70,
Means, I AM Secondary to refers to fluid transfusion. by providing Tachycardia
DIZZY, THIRSY Increase in dehydration, replacement, route for IV resolved as
AND I FEEL SO Vascular water loss Patient will fluid evidenced by
WEAK" ] Permeability alone without gradually replacement a normal HR of
change in to save time 80bpm. CRT
abate signs
sodium and decrease decreased
OBJECTIVE : and symptoms 2. Obtain risk for from 7s down
Fluid volume of fluid volume doctor’s order complications. to 4s and
+ Sunken, Dry deficit, or deficiency as for IV therapy there is a
eyes hypovolemia, evidenced by 2. IV is noticeable
As soon as
+ Pale occurs from a increasing considered as improvement
palpebral possible to MEDICATION. in the client’s
loss of body blood
conjunctiva fluid or the replace fluid Before skin turgor.
pressure, volume loss
+ Dry lips and shift of fluids initiating IV
mouth decreasing IMMEDIATELY. Replacement
into the third
+Prolonged space, or from heart rate, therapy, make {LONG TERM :
Capillary refill a reduced fluid improving sure that there 2 Days after a
time [ 7 intake. capillary refill is a current series of
seconds ] Common time standing or nursing care,
+ Poor skin sources for preferably verbal order the patient
turgor fluid loss are 3. Encourage from the manifested a
below 5s and
+ Rapid, the fluid intake by doctor. normal urine
Thready Pulse an improving output of 30ml
gastrointestina placing a glass
 skin turgor. of juice or per hour with
Heart rate – l (GI) tract, water within 3. Placing a a specific
110 Bpm polyuria, and { LONG the patient’s glass of water gravity of
RR – 21 Bpm increased or juice at 1.011. Stable
TERM : After 2 reach.
BP – 90/60 perspiration. patient’s vital signs
Temp – 39.2 C days of bedside is the were
Fluid volume
deficit may be nursing best way to monitored and
an acute or intervention, encourage recorded. CRT
chronic Patient will fluid intake. was recorded
condition maintain fluid DHF patient normal.
managed in volume at an are always Physical
the hospital, thirsty prior to assessment
amount 4. Monitor
outpatient the revealed no
optimum for total fluid defervescence sign of fluid
center, or
home setting. normal intake and stage. deficit.}
The functioning as output every 2
therapeutic evidenced by hours. 4. A urine
goal is to treat a normal urine output of .5 ml
the underlying output with per kg/hr is
disorder and insufficient for
normal
return the 5. Watch normal renal
extracellular specific function and
gravity, stable trends in
fluid indicates
vital signs, output for 3 onset of renal
compartment
to normal. moist mucus days; include damage
Treatment membrane, all routes of
consists of good capillary intake and 5. Monitoring
restoring fluid output and for trends for 2
refill time and
volume and note color and to 3 days
correcting any resolution of gives a more
third specific
electrolyte valid picture of
imbalances. spacing.} gravity of the client's
Early urine. hydration
 status than
recognition monitoring for
and treatment a shorter
are paramount period. Dark-
to prevent colored urine
potentially life- with
threatening increasing
hypovolemic 6. Monitor vital specific
shock. signs of clients gravity reflects
with deficient increased
fluid volume urine
concentration.
every hour.
Observe for 6. To monitor
decreased and assess
pulse pressure client’s
first, then response and
hypotension, progress in the
tachycardia, fluid
replacement
decreased therapy.
pulse volume,
and increased
or decreased
body
temperature
ECOLOGIC MODEL:

A. Hypothesis

DHF is a more severe form of dengue. It can be fatal if unrecognized and not properly treated. DHF is caused
by infection with the same viruses that cause dengue. With good medical management, mortality due to DHF can be
less than 1%.

B. Predisposing Factors

1. Host

a. age – 18 years old

b. sex- female

c. behavior- doesn’t have proper hygiene.

2. Agent

3. Environment

a. Physical- rural (use of woods in cooking)

C. Ecologic Model
D. Analysis

E. Conclusion and Recommendations

It can be inferred in the statements above that the client is suffering from Dengue hemorrhagic fever and can
plausibly be caused by the lowered immune system of the client from the identified pre-disposing risk factors. It may
have been the damaged caused by his previous lifestyle and environment.