XI.

NURSING CARE PLAN ASSESSMENT DIAGNOSIS BACKGROUND STUDY OF DIAGNOSIS The signs and symptoms of dengue shock syndrome are related to damage to the blood vessels and derangement in functioning in components of blood that help it to clot. During fever, the damage may range from increased permeability of the blood vessels, causing leakage of blood fluid/plasma into various organs to completely broken blood vessels that may cause bleeding. PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Mataas ang lagnat ng anak ko. as verbalized by the patients mother. Objective: - Flushed skin - Tachypnea Vital Signs: T: 39.9C PR: 79 bpm RR: 35 cpm BP: 90/60 mm Hg

Hyperthermia related to Dengue Shock Syndrome as manifested by increase in body temperature, skin flushing and tachypnea

Short- term: To decrease the patients body temperature to 38 C or less in 1 hour. Long-term: To maintain patients core temperature within normal range (36.7-37.5 C) at the end of the shift.

Independent: Give tepid sponge baths Monitor vital signs and skin color. Maintain bedrest

To adjust altered body temperature To detect elevation in temperature. To reduce metabolic demands/ oxygen consumption To bring down temperature To prevent dehydration

After 1 hour of nursing intervention, clients temperature reading is 38C and at the end of the shift, the patients temperature is 37.4 C.

Give proper ventilation Advise patient to increase fluid intake Collaborate: Provide supplemental oxygen

To offset increased oxygen demands and

consumption Administer replacement fluids Provide highcalorie diet To prevent dehydration To meet increased metabolic demands To fever reduce

Dependent: Administer antipyretics ordered

as

Health teaching: Discuss importance of adequate fluid intake Review signs and symptoms of hyperthermia

To support circulating volume and tissue perfusion To indicate need of prompt intervention

XII.

DRUG STUDY
NAME DRUG OF CLASSIFI -CATION MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS ADVERSE EFFECTS DRUG TO DRUG NURSING INTERACTIONS CONSIDERATIONS

Furosemide (Lasix)

Loop diuretic

Inhibits Na & Cl reabsorption at proximal and distal tubules and ascending loop of Henle; promotes water and Na secretion.this results in the excretion of Na, Cl and to a lesser degree Potassium and Bicarbonate ions. The resulting urine is more acid.

Acute pulmonary edema, edema, heart failure and chronic renal impairment, hypertensio n, hypercalce mia

Contraindicated to hypertensive patients. Use cautiously in pt. with hepatic cirrhosis. In pt. with allergy to sulfonamide.

CNS: dizziness, fever, headaches, restlessness CV: orthostatic hypotension , thrombophl ebitis, dehydration

Aminoglycosides/ Assess pt. underlying Antibiotics may condition. Monitor potentiate toxicity. weight, peripheral edema, breath Antidiabetics may sounds, BP, fluid intake and output, decrease and electrolytes hypoglycemic glucose, BUN, and effect. carbon dioxide levels. Monitor uric acid Antihypertensives may increase risk of level especially if the pt. has a history of hypertension. gout. Assess pt. and NSAIDs may familys knowledge inhibit diuretic of drug therapy. response.

GI: anorexia, constipation , diarrhea, pancreatitis, Salicylates may nausea and cause salicylates vomiting toxicity.

NAME DRUG

OF CLASSIMECHAINDICATIONS FICATIONS NISM OF ACTION

CONTRAINDICATIONS

ADVERSE EFFECTS

DRUG TO DRUG INTERACTIONS

NURSING CONSIDERATIONS

Paracetamol (Tempra)

Analgesic Antipyretic

Analgesic : Site and mechanis m of action unclear

Fever and Allergy to minor aches and paracetamol pains due to / colds, flu, sore acetaminop throat, hen headaches and toothaches; pain Use migraine cautiously in Antipyret of headaches. ic: patients with Reduces impaired fever by hepatic acting function, directly on chronic the alcoholism hypothala mic heatregulating center to cause vasodilati on and sweating, which helps dissipate heat.

CNS: Headache CV: Chest pain, dyspnea, myocardial damage Hematologic: hemolytic anemia, hematuria, pancytopenia

Increased toxicity Check body with long-term, temperature excessive ethanol ingestion Inspect skin color Increased risk of hepatotoxicity and possible decreased therapeutic effects with barbiturates, carbamezepine, hydantoins, rifampicin Do not exceed recommended dosage; do not take for longer than 10 days

Treatment of overdose: Monitor serum levels regularly, Nacetylcysteine Possible delayed should be available a specific or decreased as antidote, basic life effectiveness with support may be anticholinergics necessary

NAME OF CLASSIFICA DRUG -TION

MECHANISM OF ACTION

INDICATION

CONTRAINDICATIONS

ADVERSE EFFECTS

DRUG TO NURSING DRUG CONSIDERATIONS INTERACTIONS

Loratadine Antihistamine (Allerta) (nonsedating type)

Competitively blocks the effects of histamine at peripheral H1 receptor sites, has anticholinergic and antipruritic effects

Symptomatic relief of perennial and seasonal allergic rhinitis, vasomotor rhinitis, allergic conjunctivitis, and mild, uncomplicated urticaria and angioedema.

Contraindicat ed with allergy to any antihistamines

CNS: headache, nervousness , dizziness CV: Palpitations, edema

Additive CNS depressant affects with alcohol or other CNS depressants.

Assess orientation, affect and respirations. Administer without regard to meals. Avoid use of alcohol, serious sedation could occur.

Use cautiously with lactation, pregnancy GI: appetite increase Other: fever, photosensiti vity, weight gain

NAME OF CLASSIFICA DRUG -TION

MECHANISM OF ACTION

INDICATION

CONTRAINDICATIONS

ADVERSE EFFECTS

DRUG TO NURSING DRUG CONSIDERATIONS INTERACTIONS

Voluven

Hydroxyethyl starch

Expands plasma volume when administered intravenously

Indicated for the treatment and prophylaxis of hypovolemia

Hyperhydratio n including pulmonary edema, renal failure with oliguria or anuria, dialysis, intracranial bleeding, sever hypernatremia or hyperchloremi a

Dermatologic No : Pruritus interactions with other or Hematologic: drugs nutritional Decrased hct products are known. Other: Anaphylavtio d rxns

If a hypersensitivity reaction occurs, administration of the drug should be discontinued immediately Fluid status and rate of infusion should be assessed regularly during treatment, especially in patients with cardiac insufficiency or severe kidney dysfunction. In cases of severe dehydration, a crystalloid solution should be given first. Generally, sufficient fluid should be administered in order to avoid dehydration.