Patient’s Name: A Hospital No.

:
Age: 13 Diagnosis: Dengue fever with warning signs
Room No. 415 Attending Physician: Dr. Sara
Student/Placement: A1 Date: 01/23/25

ASSESSMENT NSG. DIAGNOSIS OBJECTIVE OF NURSING RATIONALE EVALUATION

W/SCIENTIFIC CARE INTERVENTION
BASIS
S: Risk for electrolyte After 8 hours of INDEPENDENT GOAL MET
"Naluya kaayu ko, nya imbalance related to nursing intervention - Monitored vital signs To detect significant
lipong ko tapos sakit dehydration and poor the patient will exhibit q4. changes in the patient’s After 8 hours of
akong ulo," as nutrition as evidenced improvement in condition that may nursing intervention
verbalized by the patient. by dizziness, symptoms (dizziness, require prompt the patient was able to
weakness, and weakness, and intervention, such as exhibit improvement in
headache. headache), with verbal administering symptoms (dizziness,
reports of feeling more electrolyte weakness, and
stable and less fatigued replacements or headache ), with verbal
by the end of the shift. adjusting fluid therapy. reports of feeling more
O: stable and less fatigued
-Educated the patient To help patients by the end of the shift.
-exhibits facial for any signs and recognize potential
grimacing symptoms of problems early and
electrolyte imbalance seek medical attention
-the patient is holding such as dry skin, promptly.
their head and appears nausea, and fatigue.
uncomfortable.
Vital Sign: - Instructed the To monitor the intake
o BP 110/60 patient/significant and output of the
o RR 22 other to record output patient so that the
o PR 94 and input as physician can observe
o Temp. 37.5 appropriate. the client’s condition.
degree
o O2sat. 97%
 - Encouraged rest and Rest helps the body
NEEDS: limit physical activity conserve energy and
Physiologic needs to reduce fatigue and recover from
prevent injury. dehydration and
electrolyte imbalance
while preventing falls
or exertion related
complications.

- Applied a cool To lower the body

compress for headache temperature naturally
relief. and provides comfort.
Temperature changes,
especially fever, can
contribute to
electrolyte imbalances
due to increased
metabolic demands,
fluid loss, and altered
cellular function.

DEPENDENT

-Administered Medications prescribed

medications as ordered to address the
by the physician. underlying cause of
electrolyte imbalance
or to prevent further
platelet destruction.

- Administered IV To maintain hydration

fluids as ordered to and electrolyte
rehydrate the patient balance.
and correct electrolyte
imbalance.
 UNIVERSAL

- Arranged a dietary To identify potential

consult to review nutrient deficiencies
nutritional needs. that may be
contributing to health
issues.

ASSESSMENT NSG. DIAGNOSIS OBJECTIVE OF NURSING RATIONALE EVALUATION

W/SCIENTIFIC CARE INTERVENTION
BASIS
S: Anxiety related to fear After 8 hours of INDEPENDENT GOAL MET
"Na hadlok mi ni mama of complications from nursing intervention, - Provided emotional To reduce stress,
kay baba jud akong low platelet count as the patient will support anxiety which can worsen After 8 hours of
platelet," as verbalized evidenced by the demonstrate reduced reduction techniques. symptoms. nursing intervention,
by the patient. patient's verbalization anxiety and develop the patient was able to
of fear. coping strategies to - Ensured a safe Ensuring a safe demonstrate reduced
manage fears related to environment. environment helps anxiety and develop
their low platelet reduce external coping strategies to
count. stressor that may manage fears related to
contribute to the their low platelet
O: patient’s anxiety. count.
Vital Sign:
o BP 110/60 - Monitored vital signs To detect physiological
o RR 22 q4 and reported changes associated
o PR 94 worsening symptoms. with anxiety.
o Temp. 37.5 Reporting worsening
degree symptoms allows for
o O2sat. 97% early intervention,
preventing
Restlessness
complications and
Shallow breathing
ensuring appropriate
Platelet count: 90 (range
management of
200-400)
patient’s condition.

- Assisted and To allows for early

monitored anxiety identification of
level. escalating symptoms
and the implemention
of appropriate
interventions.

- Educated the patient To helps increase

about their condition. awareness and
understanding of
anxiety, reducing fear
of the unknown. It
empowers the patient
with knowledge about
triggers, symptoms,
and coping strategies,
 promoting self-
management and
enhancing their ability
to control anxiety
effectively.

- Educated and Educating and

encouraged coping encouraging coping
strategies. strategies help the
patient develop
effective ways to
manage anxiety,
reducing distress and
promoting emotional
well-being.

DEPENDENT

- Provided oxygen as Anxiety can cause

prescribed by the hyperventilation,
physician for supplemental oxygen
experiencing helps regulate
hyperventilation. breathing and prevent
complications.

- Monitored and Maintaining proper

regulated intravenous hydration and
fluids if dehydration or electrolyte balance
electrolyte imbalance prevents complications
occurs due to anxiety- such as dizziness,
related symptoms (e.g., weakness, and
excessive sweating, increased heart rate,
nausea, or vomiting). which can exacerbate
anxiety symptoms.
ASSESSMENT NSG. DIAGNOSIS OBJECTIVE OF NURSING RATIONALE EVALUATION
W/SCIENTIFIC CARE INTERVENTION
BASIS
S: Risk for dehydration After 8 hours of INDEPENDENT GOAL MET
"Wala jud siyay gana related to vomiting and nursing intervention, - Assisted patient’s Facilitates in planning
mokaon, niya malipong decreased food and the patient will perceptions regarding for meals that are After 8 hours of
daw siya tapos isuka ang fluid intake as demonstrate improved food intake and food appropriate for the nursing intervention,
kinaon," as verbalized evidenced by patient nutritional intake as preferences. patient’s condition. the patient was able
by the patient’s mother. reports of vomiting and evidenced by the demonstrate improved
lack of appetite. ability to tolerate food -Allowed patient to Allowing patient to nutritional intake as
and fluids and a select food preferences select her menu based evidenced by the
reduction in vomiting. from the approved on the approved list ability to tolerate food
food list for her allows her to choose and fluids and a
 condition (excluding options that are reduction in vomiting.
O: dark-colored food; palatable to her.
V/S taken as food containing
follows colorants, etc..)

o BP 110/60 -Encouraged the Eating smaller meals

mmHg patient to have small spaced throughout the
o RR 22 cpm frequent feedings, day encourages the
o PR 94 bpm eating at least once patient to eat according
o Temp. 37.5 every 3-4 hours. to the recommended
degree meal without
o O2sat 97% overwhelming her.

-Lethargic -Instructed patient to Helps stimulate

-Lack of appetite brush teeth regularly, appetite by removing
refraining from strong plaque and unpleasant
mouthwash solutions. taste and sensation that
may be in the mouth
due to intake of
medications or after
vomiting.

DEPENDENT

-Included supplements Help meet daily

in patient’s dietary requirements of
intake as prescribed by essential nutrients.
the physician.

-Administered anti Prevent regurgitation

emetics as prescribed of ingested food.
by the physician.