Saint Louis University
Baguio City, Philippines
School of Nursing
NURSING CARE PLAN
PR/ANNEX
June 21-23, 2021 7-5 shift
Submitted by:
Daoay, Karen Z.
BSN 3- G1
Submitted to:
Mrs. Lilian G. Caballes, RN
I. PATIENT PROFILE
Name: C.A
Age: 29 years old
Sex: Male
BMI: 40 (Obese II)
Date of birth: July 3, 1991
Address: Western Buyagan, La Trinidad, Benguet
Marital status: Married
Nationality: Filipino
Religion: Jehovas Witness
Allergies: None
Admission date: June 18, 2021
Informant: Wife
II. PATIENT HISTORY
A. History of Present Illness
• Chief complaint: Dengue Fever
• When the chief complaint started: June 18, 2021
• Associated signs and symptoms of the chief complaint: Fever
• Medications taken: None
• Diagnostics done: CBC, Lipid Profile
• Description of patient’s experience of the current illness from onset of signs
and symptoms until contact with healthcare providers:
Three days prior to admission, patient has fever with maximum temperature of 38.4
degrees Celsius, with chills but no nausea and vomiting. Two days prior, he had headache
rated 10/10 radiating to back, with nausea and vomiting. Vomitus containing food
particles. Few hours prior to admission, he had generalized body weakness, headache that
is persistent. The persistence of headache, body weakness prompted the wife to bring the
patient to the ER to seek consultation. He was admitted in Saint Louis University
Hospital of the Sacred Heart – Private Room/ Annex with an admitting diagnosis of
Dengue Fever under Dr. Jason Roy Bacani as attending physician.
B. Past Medical
Date of Hospitalization Condition/Reason Institution
2018 Hypertension Unknown
2013 Appendectomy Unknown
- Diagnosed with hypertension in 2018 with maintenance of Telmisartan and Amlodipine.
Last 2013, he had appendectomy. No other diseases such as diabetes, heart disease,
chronic kidney disease, PTB, bronchial asthma and allergy.
C. Family History
- Patient has no family history of hypertension on both sides paternal and maternal. No
family history of colon cancer, DM, asthma, TB, thyroid disease, and blood dyscrasia.
D. Social and Environmental
- Patient lives in a well-ventilated two-story house with two occupants, non-congested
neighbor. His diet consists of rice, vegetable, and meat. No history of travel. Drinking
water comes from refilling station and with flush-type toilets. He is a 6-pack year smoker.
E. Review of System
Skin: (-) rashes, (-) itching, (-) change in hair and nails
Head: (+) headache, (-) head injury, (+) awake, (+) alert
H.E.E.N.T.: (-) change in vision, (-) eye pain, (-) ear pain, (-) ringing, (+)
dizziness, (-) nose bleeds, (-) bleeding gums, (-) sore throat
Respiratory: (-) shortness of breath, (-) cough, (-) crackles, (-) wheezes
CVS: (-) chest pain, (+) high blood pressure, (-) heart murmur
GIT: (+) change in appetite, (+) nausea, (+) vomiting, (-) abdominal pain
Urinary: (-) difficulty in urination, (-) blood in urine
Musculoskeletal: (+) pain, (-) swelling, (-) stiffness
Neurologic: (+) headaches, (-) seizures), (+) weakness, (-) paralysis
Hematologic: (-) Anemia, (-) Easy bruising
Endocrine: (-) abnormal growth, (-) thyroid trouble
III. DIAGNOSTIC & LABORATORY RESULTS
CBC- 2/21/21
- Hb- 15.3 g/dL
- Hct- 0.44
- Platelet- 135 k/uL
- WBC- 3.3 k/uL
- Neutrophils- 56.5
- Lymphocytes- 32.5
- Monocytes- 9.5
- Eusinophils-1.2
Lipid Profile- 2/21/21
- Cholesterol - 154. 41mg/dL
- Triglycerides - 396. 48 mg/dL
- HDL-C - 29.8 mg/dL
- LDL -C- 45.28 mg/dL
IV. LIST OF PROBLEMS
- Risk for bleeding related to decreased platelet count
- Impaired comfort related to headache and feeling of bloated.
- Risk for infection related to low white blood cells count.
V. PRIORITIZATION AND JUSTIFICATION
Rank Nursing Diagnoses Justification
1 Risk for bleeding related to decreased Dengue fever causes infected platelets to
platelet count. destroy normal platelets that will cause
his platelet count to decrease. Dengue
Cues: virus also suppresses bone marrow thus
- “Bigla bumaba yung platelet causing low platelet. Since the patient has
niya” as verbalized by the dengue with a laboratory result of
significant other. 135k/uL this makes the patient at risk for
- Looks weak and tired, with bleeding since platelet works by stopping
intact skin, dry, pinkish skin bleeding through clotting.
color and warm to touch. According to Maslow’s hierarchy of
With vital signs of: BP= needs blood belongs to our physiologic
130/80. PR=75 bpm, RR= 20 need that should be prioritized first
cpm, Temp= 36.4 C and before the others. Blood and platelets are
SpO2= 95%. Laboratory important in our lives such as in our
shows platelet count of 135 oxygen, fighting infections or for our
K/uL. immunity. Since the patient should be
checked out for bleeding and that the
main problem why he is still in the
hospital is his low platelet count that is
why I prioritized this problem first. Risk
for bleeding should be prioritized in order
to prevent it from becoming an actual
problem that may cause further
complications. Once it becomes an actual
problem the severity becomes life-
threatening. More of his symptoms and
laboratory results are more on his risks
for bleeding. Even though it is not an
actual problem prioritizing this may help
prevent the other problems below.
2 Impaired comfort related to headache and This is an actual problem experienced by
feeling of bloated. the patient due to feeling of bloated and
headache that may be related to his
Cues: diagnosis dengue fever. Since the patient
- “Medyo bloated parin has no physical activities, this may cause
pakiramdam ko”. the patient to be constipated as well.
- Comfort scale of 4/10. Patients with classic dengue fever had a
Headache rated 3/10, looks more intense headache than those with
tired and weak, and stays on the more severe form of the disease,
bed. Pain alleviated when dengue haemorrhagic fever. Headache
asleep but has difficulty features in patients with dengue virus
having a comfortable sleep. infection (RB Domingues et al.)
Flabby abdomen and
nontender, with normal bowel According to Maslow’s hierarchy of
movement and flatus. needs, comfort belongs to our
psychological, emotional, safety, and
security needs; this also includes a low
level of stress and anxiety that is why it is
prioritized as the second. In the case of
the patient, she had an impaired comfort
due to his headache due to his dengue
fever as well as his feeling of bloated that
is uncomfortable for him. Prioritizing this
will help the patient to gain comfort to
help himself to take care of himself. The
patient is also experiencing stress and
anxiety due to her situation that causes a
disruption in her comfort.
3 Risk for other infection related to low This is my last prioritization since the
WBC count. patient has no signs and symptoms that
may entail infection except CBC results
Cues: of low WBC count that puts the patient at
- CBC results: risk for infection. The patient may be
WBC- 3.3 k/uL recovering from the dengue fever which
Monocytes- 9.5 is an infection itself, but this risk problem
Eosinophils 1.2 is about getting infection of other kinds
- Intact skin due to his decreased WBC. Nursing
- Temp- 36.9 degrees Celsius interventions is important to help reduce
the risk for infection including
implementing strategies to prevent
infection.
According to Maslow’s hierarchy of
needs this belongs to physiological needs
and safety since it is one of our needs in
order to survive another is that breakage
in our immune system causes our safety
at risk for infection that may lead to other
complications or problems.
VI. PATHOPHYSIOLOGY
VII. REFERENCES
Belleza, M. (2021, February 20). Dengue Hemorrhagic Fever Nursing Care Management and Study
Guide. Nurseslabs. https://nurseslabs.com/dengue-hemorrhagic-fever/#see_also.
Berman, A., Snyder, S. J., Kozier, B., Erb, G. L., Levett-Jones, T., Dwyer, T., … & Parker, B. (2014).
Kozier & Erb’s Fundamentals of Nursing Australian Edition (Vol. 3). Pearson Higher Education
AU.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, prioritized
interventions, and rationales. Philadelphia: F.A. Davis.
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: diagnoses, interventions, & outcomes. St. Louis,
MO: Mosby, an imprint of Elsevier Inc
Muehlenbachs, A., & Zaki, S. R. (n.d.). Pathology of dengue virus infection. Dengue and Dengue
Hemorrhagic Fever, 284–292. https://doi.org/10.1079/9781845939649.0284
Tata Digital Health. (n.d). Dengue: understanding platelet level count.
https://www.tatahealth.com/article/dengue-understanding-platelets-level-count.
