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NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION


Independent:
Subjective: • Injury, risk for • This infectious • After 1 hr. Of • Assess for signs • The G.I tract • After 1 hr. Of
hemorrhage disease is nursing and symptoms of (esophagus and nursing
“Dumudugo ang related to interventions, G.I bleeding. rectum) is the interventions,
manifested by
ilong ng anak ko” altered clotting the client will Check for most usual the client
a sudden
(My son’s nose is factor. be able to secretions. source of was able to
onset of fever,
bleeding) as demonstrate Observe color bleeding of its demonstrate
with severe
verbalized by the behaviors and consistency mucosal behaviors
headache,
mother. that reduce of stools or fragility. that reduce
muscle and
joint pains the risk for vomitus. the risk for
Objective: bleeding. • Observe for • Sub-acute bleeding.
(myalgias and
arthralgias— presence of disseminated
• Weakness and severe pain petechiae, intravascular
irritability. gives it the ecchymosis, coagulation
name break- bleeding from one (DIC) may
• Restlessness. bone fever or more sites. develop
bonecrusher secondary to
• V/S taken as disease) and altered clotting
follows: rashes and factors.
usually • Monitor pulse, • An increase in
T: 38 appears first Blood pressure. pulse with
P: 55 on the lower decreased
R: 18 limbs and the Blood pressure
chest. There can indicate
may also be loss of
gastritis and circulating
some times blood volume.
bleeding. • Note changes in • Changes may
mentation and indicate
level of cerebral
consciousness. perfusion
secondary to
hypovolemia,
hypoxemia.
• Avoid rectal • Rectal and
temperature, be esophageal
gentle with GI vessels are
tube insertions. most vulnerable
to rupture.
• Encourage use of • In the presence
soft toothbrush, of clotting factor
avoiding straining disturbances,
for stool, and minimal trauma
forceful nose can cause
blowing. mucosal
bleeding.
• Use small • Minimizes
needles for damage to
injections. Apply tissues,
pressure to reducing risk for
venipuncture bleeding and
sites for longer hematoma.
than usual.

• Recommend • Prolongs
avoidance of coagulation,
aspirin containing potentiating risk
products. of hemorrhage.

Collaborative:
• Monitor Hb and • Indicators of
Hct and clotting anemia, active
factors. bleeding, or
impending
complications.