Here's a nursing care plan for a patient with dengue. It includes potential nursing diagnoses, goals, interventions, and rationale.
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### **Nursing Care Plan for Dengue**
#### **Patient Information**
- **Name**: [Patient’s Name]
- **Age**: [Age]
- **Gender**: [Gender]
- **Diagnosis**: Dengue Fever
### **Nursing Assessment for Dengue Fever**
### **1. Subjective Data**
- **Chief Complaint**:
- Fever, headache, muscle or joint pain, fatigue, nausea, abdominal pain.
- **History of Present Illness**:
- Duration of fever and associated symptoms (e.g., rash, bleeding tendencies).
- History of mosquito bites or travel to endemic areas.
- **Past Medical History**:
- Previous dengue infection (risk of severe dengue increases with subsequent infections).
- Any pre-existing conditions (e.g., liver disease, immune disorders).
- **Family and Social History**:
- Presence of similar illnesses in the household.
- Recent exposure to mosquitoes in the living or work environment.
- **Medications**:
- Use of NSAIDs (e.g., ibuprofen, aspirin) or anticoagulants that increase bleeding risk
### **2. Objective Data**
#### **Vital Signs**
- **Temperature**: Elevated (fever during the febrile phase).
- **Pulse**: May be rapid and weak (indicative of dehydration or shock in severe cases).
- **Blood Pressure**: Monitor for hypotension (may suggest hypovolemia or shock).
#### **Physical Examination**
- **General Appearance**:
- Fatigue, lethargy, or restlessness.
- **Skin**:
- Petechiae, purpura, or ecchymoses (indicate bleeding tendencies).
- Rash (maculopapular or erythematous, common in dengue).
- Assess for delayed capillary refill (indicates poor perfusion).
- **Mucous Membranes**:
- Dryness (indicates dehydration).
- Check for bleeding from gums or nose.
- **Abdomen**:
- Tenderness or signs of ascites (may indicate severe dengue or organ involvement).
- **Extremities**:
- Cold or clammy skin in case of shock.
- **Neurological Status**:
- Assess level of consciousness (any confusion or altered sensorium may indicate severe dengue or shock).
#### **Fluid Status**
- Monitor for signs of dehydration:
- Decreased skin turgor.
- Reduced urine output or dark-colored urine.
- Dry lips or tongue.
### **Nursing Diagnosis 1:
Fluid Volume Deficit related to increased vascular permeability, fever, and reduced oral intake**
**Goal:**
The patient will maintain adequate hydration, as evidenced by stable vital signs, improved skin turgor, and balanced intake and output.
**Interventions:**
1. **Monitor vital signs frequently** (e.g., blood pressure, pulse, temperature) to detect signs of hypovolemia or hemodynamic instability.
- *Rationale:* Early detection allows timely interventions to prevent complications such as shock.
2. **Assess for signs of dehydration** (e.g., dry mucous membranes, reduced skin turgor, decreased urine output).
- *Rationale:* These are key indicators of fluid deficit.
3. **Encourage oral fluid intake** (e.g., oral rehydration salts, water, clear fluids) if the patient is not vomiting.
- *Rationale:* Oral hydration is the simplest way to replenish fluids.
4. **Administer intravenous fluids as prescribed**, monitoring for signs of fluid overload.
- *Rationale:* IV fluids ensure effective hydration in patients unable to tolerate oral intake.
5. **Monitor urine output and color** using a Foley catheter if necessary.
- *Rationale:* Reduced output indicates dehydration or kidney involvement.
### **Nursing Diagnosis 2: Hyperthermia related to the febrile phase of dengue fever**
**Goal:**
The patient will maintain a body temperature within normal limits, as evidenced by reduced fever and absence of discomfort.
**Interventions:**
1. **Monitor body temperature every 4 hours.**
- *Rationale:* Early detection of fever spikes allows prompt management.
2. **Provide tepid sponge baths and encourage wearing light clothing.**
- *Rationale:* These measures help reduce body temperature without inducing chills.
3. **Administer antipyretics as prescribed** (e.g., paracetamol/acetaminophen).
- *Rationale:* Antipyretics lower fever and improve comfort. Avoid NSAIDs like ibuprofen to prevent bleeding complications.
4. **Encourage adequate hydration.**
- *Rationale:* Fluids assist in temperature regulation and prevent dehydration.
5. **Provide a cool, well-ventilated environment.**
- *Rationale:* A comfortable environment helps in maintaining normal body temperature.
### **Nursing Diagnosis 3: Risk for Bleeding related to thrombocytopenia and capillary fragility**
**Goal:**
The patient will remain free from bleeding complications, as evidenced by stable hemoglobin levels and absence of visible bleeding.
**Interventions:**
1. **Monitor platelet counts and coagulation parameters daily.**
- *Rationale:* Early identification of thrombocytopenia guides timely interventions.
2. **Assess for signs of bleeding** (e.g., petechiae, bruising, epistaxis, hematuria).
- *Rationale:* Prompt recognition of bleeding enables early treatment.
3. **Avoid invasive procedures** unless absolutely necessary, and use smallest gauge needles if required.
- *Rationale:* Minimizes the risk of bleeding in thrombocytopenic patients.
4. **Educate the patient to avoid activities that could cause trauma** (e.g., vigorous brushing, contact sports).
- *Rationale:* Reduces the likelihood of accidental bleeding.
5. **Administer blood or platelet transfusions as prescribed** for severe thrombocytopenia.
- *Rationale:* Replenishes depleted platelets and supports clotting.
### **Evaluation**
- The patient demonstrates improved hydration status, as evidenced by normal skin turgor, stable blood pressure, and urine output of at least 30 mL/hr.
- The patient’s temperature is maintained within the normal range without chills or discomfort.
- The patient remains free from bleeding, with no signs of petechiae, epistaxis, or other hemorrhagic manifestations.
Feel free to adjust this plan according to the patient's specific condition and your healthcare facility's protocols. Let me know if you'd like additional details!
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