Systems Plus College Foundation

Balibago, Angeles City

College Of Nursing

Nursing Care Plan

Student Nurse: Kimberly Trisha R. Concepcion
Yr/Level: 4th year
Date: 09/19/13

Cues
SO
Muscle grade
of 2/5
With pallor
Platelet: 100 x
109 L
With V/S as
follows
36.6 C
89 bpm
19 cpm
150/70 mmHg

Nursing
Diagnosis
Risk for
bleeding
related to
altered
clotting
factor

Scientific
Explanation
The circulatory
system protects
itself from
excessive blood
loss. Vascular
injury activates
platelet
aggregation
which causes
adherence of
circulating
platelets to
collagen fibers
that will activate
the adenosine
diphosphate
causes platelet
to breakdown

Medical Diagnosis: DFS warning signs

Age: 16 Sex: F

Objectives
After 5 hours of
nursing
intervention the
patient will be
able to be free
of signs of
bleeding in GI
aspirate or
stools, with
stabilization of
Hgb and Hct.

Nursing
Interventions
Note color and
characteristics of
vomitus and stools.

Rationale

Evaluation

The first step in

managing bleeding is
to determine its
location. Bright red
blood that does not
clear signals recent or
acute arterial
bleeding, perhaps
caused by gastric
ulceration; dark red
blood may be old
blood that has been
retained in intestine or
venous bleeding from
varices. Coffeeground appearance is
suggestive of partially
digested blood from

What is the color of

the stool of the
patient?

and stick
together that
will aggregate
the platelet to
plug the wound.
Platelet are
responsible for
clotting factor in
our blood.
(Medical
Surgical
Nursing 2nd
Edition, Udan
2009)

slowly oozing area.

Undigested food
indicates obstruction
or gastric tumor. In a
rapid upper GI bleed,
stool color may be red
or maroon because of
rapid transit time
through the GI tract.
Monitor vital signs;
compare with
clients normal and
previous readings.
Take blood
pressure (BP) in
lying, sitting, and
standing positions
when possible.

Changes in BP and
pulse may be used for
rough estimate of
blood loss; BP less
than 90 mm Hg and
pulse greater than 110
suggest a 25%
decrease in volume,
or approximately
1,000 mL. Postural
hypotension reflects a
decrease in circulating
volume. Note: Heart
rate may not rise
above normal until up
to 30% of total blood
volume is lost.

What are the vital

signs of the
patient?

Note clients
individual
physiological
response to
bleeding, such as
changes in
mentation,
weakness,

Symptomatology is
useful in gauging
severity and length of
bleeding episode.
Worsening of
symptoms may reflect
continued bleeding,
inadequate fluid

Did the patient

manifest any
change in mental
status?

restlessness,
anxiety, pallor,
diaphoresis,
tachypnea, and
temperature
elevation.

replacement, and
shock.

Monitor intake and

output (I&O) and
correlate with
weight changes.
Measure blood
and fluid losses via
emesis and stools.

Provides guidelines
for fluid replacement.

What is the I & O of

the patient? Did the
patient experience
fluid loss?

Keep accurate
record of subtotals
of solutions and
blood products
during
replacement
therapy.

Potential exists for

overtransfusion of
fluids, especially when
volume expanders are
given before blood
transfusions.

Did the patient

need a blood
transfusion?

Maintain bedrest;
prevent vomiting
and straining at
stool. Schedule
activities to provide
undisturbed rest
periods. Eliminate
noxious stimuli.

Activity and vomiting

increases intraabdominal pressure
and can predispose to
further bleeding.

Did the patient

understands the
instructions given?

Note signs of
renewed bleeding
after cessation of
initial bleed.

Increased abdominal
fullness and
distention, nausea or
renewed vomiting, and

Did the patient

experience a
renewed bleeding?

bloody diarrhea may

indicate return of
bleeding.
Observe for
secondary
bleeding from nose
or gums, oozing
from puncture
sites, or
appearance of
ecchymotic areas
following minimal
trauma.

Loss of or inadequate
replacement of clotting
factors may precipitate
development of
Disseminated
Intravascular
Coagulation.

Provide clear or
bland fluids when
intake is resumed.
Instruct to. Avoid
caffeinated and
carbonated
beverages.

More easily digested

and reduce risk of
added irritation to
inflamed tissues.
Caffeine and
carbonated beverages
stimulate hydrochloric
acid (HCl) production,
possibly potentiating
bleeding.

Did the patient

understand the
instructions given?

Instruct to avoid
dark colored foods.

Dark colored foods

that will darken the
stool. That you may
confuse it with
bleeding.

Did the patient

comply with the
instructions given?

Instruct to avoid
Aspirin intake.

Aspirin is an antiplatelet medication

that prevents forming

Did the patient

comply with the
instructions given?

Did the patient

experience
secondary
bleeding?

clot
Monitor laboratory
studies: Hgb, Hct,
RBC count, and
BUN/creatinine
levels.

Administer
medications, as
indicated:Proton
pump inhibitors
(PPIs), such as
omeprazole.

Aids in establishing
blood replacement
needs and monitoring
effectiveness of
therapy; for example,
1 unit of whole blood
should raise Hct two
to three points. Levels
may initially remain
stable because of loss
of both plasma and
RBCs. Note: Levels
may not accurately
reflect early or sudden
blood loss, and low
baseline levels may
indicate preexisting
anemia. BUN greater
than 40 with normal
creatinine level
indicates major
bleeding. BUN should
return to clients
normal level
approximately 12
hours after bleeding
has ceased.
Proton pump inhibitors
have been shown in
studies to be most
effective after GI bleed
to reduce recurrence
of bleeding.

What are the

laboratory results of
the patient?

Did the patient

manifest any
recurrence of
bleeding after
taking the
medication?

Cues
S Naiinip na
ako dito
O
Muscle grade
of 2/5
Lethargic
Moves from
side to side

Restlessness
Lack of
interest in
eating
With V/S as
follows
36.6 C
89 bpm
19 cpm
150/70 mmHg

Nursing
Diagnosis
Deficient
diversional
activity related
to
environmental
lack of
diversional
activity as
evidenced by
restlessness

Scientific
Explanation
The nervous
system
profoundly
affects both
psychological
and physiologic
functions. It
receives stimuli
from the internal
and external
environmen5
through a varied
afferent or
sensory
pathways that
will
communicates
information
between the
distant parts of
the body to
CNS that will
also transmits
information
rapidly over
varied efferent
or motor
pathways to
effector organs
for body action
control or
modifications.
(Medical
Surgical
Nursing 2nd
Edition, Udan

Objectives
After 4 hours of
nursing
intervention, the
patient will be
able to engage
in satisfying
activities within
personal
limitations.

Nursing
Interventions
Assess/review
clients physical,
cognitive,
emotional, and
environmental
status.

Rationale

Evaluation

Validates reality of
diversional deprivation
when it exists, or
identifies the potential
for loss of desired
diversional activity, in
order to plan for
prevention or early
intervention where
possible.

What is the
patients physical,
cognitive, emotional
and environmental
status?

Determine
avocation and
hobbies client
previously pursued.
Incorporate
activities, if
appropriate, into
present program.

Encourages
involvement and helps
to stimulate client
mentally and physically
to improve overall
condition and sense of
well-being.

What are the

patients hobbies
before
hospitalization?

Introduce activities
at clients current
level of functioning,
progressing to more
complex activities,
as tolerated.

Provides opportunity
for client to experience
successes, reaffirming
capabilities and
enhancing self-esteem.

Did the patient

comply with the
activity?

Establish
therapeutic
relationship,
acknowledging
reality of situation
and clients
feelings.

May be feeling sense

of loss when unable to
participate in usual
activities or to interact
socially as desired.

Determine what the

patient feels about
her situation?

2009)

Participate in
decisions about
timing and spacing
of visitors, leisure
and care activities

To promote
relaxation/reduce
sense of boredom as
well as prevent
overstimulation and
exhaustion.

Did the patient feel

comfortable?

Encourage
participation in mix
of activities and
stimuli, such as
music, news
program,
educational
presentations,
crafts, and social
interactions, as
appropriate.

Offering different
activities helps client to
try out new ideas and
develop new interests.
Activities need to be
personally meaningful
for the client to derive
the most enjoyment
from them such as
talking or Braille books
for the blind and
closed-caption TV
broadcasts for the deaf
or hearing impaired.

Did the patient

participate in the
given activity?

Provide change of
scenery when
possible, alter
personal
environment.

Stimulates energy and

provides new outlook
for client.

Did the patient feel

comfortable?

Systems Plus College Foundation

Balibago, Angeles City
College Of Nursing

Drug Study
Student Nurse: Concepcion, Kimberly Trisha R.
Yr/Level: 4th year
Date: Sept 14, 2013

Name Of The
Drug

Date Ordered

Route Of
Administration

Medical Diagnosis: DFS warning signs

Age: 16
Sex: F

General
Action

Specific Action

Indication

Clients
Response With
Actual Adverse
Reactions

Proton Pump
Inhibitor,
Antisecretory
drug

Gastric acid-pump
inhibitor: Suppresses
gastric
acid secretion by specific
inhibition of the
hydrogen-potassium
ATPase enzyme system
at the secretory surface of
the gastric parietal
cells; blocks the final step
of acid production.

Reduction of risk
of upper GI bleeding
in critically ill
patients;
includes sodium
bicarbonate

The patient did

not manifest any
upper GI
bleeding.

Date Started
Date Changed
Date
Discontinued
GENERIC
NAME:

DO: Sept 12,

2013

Omeprazole

DS: Sept.12,
2013

Dosage And
Frequency Of
Administration

Oral 20 mg/cap BID

Given @ 8am

BRAND
NAME:
Prilosec

Contraindication:
Contraindicated with hypersensitivity to omeprazole or its components.
Use cautiously because of possible increarisk of Clostridium difficile infection.
Adverse effects
CNS: Headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety, paresthesias, dream abnormalities
Dermatologic: Rash, inflammation, urticaria, pruritus, alopecia, dry skin
GI: Diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth, tongue atrophy
Respiratory: URI symptoms, cough, epistaxis
Other: Cancer in preclinical studies, back pain, fever, decreased bone density, bone fractures
Nursing Responsibilities:
Assessment
History: Hypersensitivity to omeprazole or any of its components, pregnancy, lactation
Physical: Skin lesions; T; reflexes, affect; urinary output, abdominal examination; respiratory auscultation
Administer before meals. Caution patient to swallow capsules wholenot to open, chew, or crush them.
Administer antacids with, if needed as per doctors order.
If patient cannot swallow Prilosec capsules, contents of capsule may be added to or sprinkled on 1 tablespoon applesauce. Mix capsule
contents into applesauce and have patient swallow immediately without chewing pellets. Follow with a glass of water.
Teaching points
Instruct the patient to take the drug before meals. Swallow the capsules whole; do not chew, open, or crush them.
If using the oral suspension, empty packet into a small cup containing 2 tablespoons of water.Stir and drink immediately; fill cup with water and
drink the water. Do not use any other liquid or food to dissolve the packet. This drug will need to be taken for up to 8 weeks (short-term therapy) or
for a prolonged period (more than 5 years in some cases).
If you take Prilosec capsules and cannot swallow them whole, capsule contents may be added to or sprinkled on 1 tablespoon of applesauce.
Mix with applesauce, swallow immediately without chewing pellets, and follow with a glass of water.
Have regular medical follow-up visits.
You may experience these side effects: Dizziness (avoid driving or performing hazardous tasks); headache (request medications); nausea,
vomiting, diarrhea (maintain proper nutrition); symptoms of URI, cough (do not self-medicate; consult your health care provider if uncomfortable).
Report severe headache, worsening of symptoms, fever, chills, severe diarrhea.

Diagnosis: DFS warning signs

Name Of The
Drug

Date Ordered

Route Of
Administration

General Action

Specific Action

Indication

Clients
Response With
Actual Adverse
Reactions

Immunostimulant

It stimulates the immune

system by inducing
activation or increasing
activity of any of its
components. One notable
example is the
granulocyte macrophage
colony-stimulating factor.

To shorten the
course of illness
and to boost the
immune system.

The patient did

not experience
any adverse
effects. The
patients white
blood cells is
within the
normal range.

Date Started
Date Changed
Date
Discontinued

Dosage And
Frequency Of
Administration

GENERIC
NAME:

DO: Sept 12,

2013

Oral 500 mg/tab

o
6

Immunosin

DS: Sept.12,
2013

Given @ 8am

BRAND
NAME:

Inosiplex

Contraindication:
Patients with
Gout
Renal disorders
Sever gastric ulcers
Pregnancy and lactation
Adverse effects:
Elevation of serum and urine uric acid values which will return to normal of the cessation of drug administration.

Nursing Responsibilities: