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UNIVERSITY OF PERPETUAL HELP SYSTEM DALT COLLEGE OF NURSING Alabang Zapote Road Pamplona Las Pinas City NURSING

CARE PLAN CUES NURSIN G DIAGNO SIS Risk for bleeding related to altered clotting factor SCIENTIFIC EXPLANATI ON 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 bonecrush er PLANNING SELECTED INTERVENTI ONS Independent : Assess for signs and symptoms of G.I bleeding. Check for Secretions. Observe color and consistency of stools or vomitus. Observe for presence of petechiae, bleeding from one more sites. IMPLEMENTE D INTERVENTI ONS Assessed for signs and symptoms of G.I bleeding. Check for Secretions. Observe color and consistency of stools or vomitus. Observed for presence of petechiae, bleeding from one more sites. RATIONALE EVALUATI ON

Subjective: No subjective cues Objective: (+) petechae on the upper part of the back Irritable Restless (-) bleeding and abdominal pain Platelet count of 25g/L as of 818-11

After 8 hrs. Of nursing interventio ns, the client will be able demonstra te behaviors that reduces the risk for Bleeding.

The G.I tract (esophagus and rectum) is the most usual source of bleeding of its mucosal Fragility.

Sub-acute disseminate d intravascula r coagulation (DIC) may develop secondary to

Goal met.After 8 of nursing Interventi on patient was able to demonstr ate behaviour that reduced the risk for bleeding.

disease) and rashes and usually appears first on the lower limbs and the chest. There may also be gastritis and some times bleeding

Monitor pulse, Blood pressure.

Monitored pulse, Blood pressure.

altered clotting factors. An increase in pulse with decreased Blood pressure can indicate loss of circulating blood volume.

Note changes in Mental status of the patient.

No changes in mental status

Encourage use of soft toothbrush, avoiding straining for stool, and forceful nose blowing.

Encouraged to use of soft toothbrush, avoiding straining for stool, and forceful nose blowing.

Changes may indicate cerebral perfusion secondary to hypovolemi a, hypoxemia.

In the presence of clotting factor disturbance

Use small needles for injections. Apply pressure to venipuncture sites for longer than usual. Recommend avoidance of aspirin containing products. Advised to increase Oral fluid intake Advised patient to eat fruits and vegetables that are high in vitamin c. Advised

s, minimal trauma can cause mucosal bleeding. Minimizes damage to tissues, reducing risk for bleeding and hematoma.

Recommend avoidance of aspirin containing products. Advised to increase Oral fluid intake Advised patient to eat fruits and vegetables that are high in vitamin c. Advised

Prolongs coagulation , potentiating risk of hemorrhag e. To prevent dehydration To boost up the immune system

patient not to eat dark colored foods.

patient not to eat dark colored foods. As it may alter the result of the stool exam in determining if theres presence of blood/ if theres GI bleeding. Indicators of anemia, active bleeding, or impending complicatio ns.

Collaborative : Monitor Hb and Hct and clotting factors.

Collaborativ e: Monitor Hb and Hct and clotting factors.