NURSING CARE PLAN
ASSESSMENT
Subjective:
“Bigla na lang
dumugo ang ilong
ng anak ko” as
verbalized by the
mother.
Objective:
•
Weakness and
irritability.
•
Restlessness.
•
V/S taken as
follows:
T: 37.5
P: 55
R: 18
Bp: 90/70
DIAGNOSIS
•
Injury, risk for
hemorrhage
related to
altered clotting
factor.
INFERENCE
•
This infectious
disease is
manifested by
a sudden
onset of fever,
with severe
headache,
muscle and
joint pains
(myalgias and
arthralgias—
severe pain
gives it the
name breakbone fever or
bonecrusher
disease) and
rashes and
usually
appears first
on the lower
limbs and the
chest. There
may also be
gastritis and
some times
bleeding.
PLANNING
•
INTERVENTION
RATIONALE
Independent:
After 1 hr. Of • Assess for signs
•
and symptoms of
nursing
G.I bleeding.
interventions,
Check for
the client will
secretions.
be able
Observe color
demonstrate
and consistency
behaviors
of stools or
that reduces
vomitus.
the risk for
bleeding.
• Observe for
•
presence of
petechiae,
ecchymosis,
bleeding from one
more sites.
•
Monitor pulse,
Blood pressure.
•
•
Note changes in
mentation and
level of
consciousness.
•
EVALUATION
The G.I tract
•
(esophagus and
rectum) is the
most usual
source of
bleeding of its
mucosal
fragility.
Sub-acute
disseminated
intravascular
coagulation
(DIC) may
develop
secondary to
altered clotting
factors.
An increase in
pulse with
decreased
Blood pressure
can indicate
loss of
circulating
blood volume.
Changes may
indicate
cerebral
perfusion
secondary to
hypovolemia,
hypoxemia.
After 1 hr.
Of nursing
intervention
s, the client
will be able
demonstrate
behaviors
that reduces
the risk for
bleeding.
•
Avoid rectal
temperature, be
gentle with GI
tube insertions.
•
•
Encourage use of
soft toothbrush,
avoiding straining
for stool, and
forceful nose
blowing.
•
•
Use small
needles for
injections. Apply
pressure to
venipuncture
sites for longer
than usual.
•
•
Recommend
avoidance of
aspirin containing
products.
•
Prolongs
coagulation,
potentiating risk
of hemorrhage.
•
Indicators of
anemia, active
bleeding, or
impending
complications.
Collaborative:
• Monitor Hb and
Hct and clotting
factors.
Rectal and
esophageal
vessels are
most vulnerable
to rupture.
In the presence
of clotting factor
disturbances,
minimal trauma
can cause
mucosal
bleeding.
Minimizes
damage to
tissues,
reducing risk for
bleeding and
hematoma.