Name: Ward: San Lorenzo Ward AP:

Age: Room #: Diagnosis:

Sex: Hospital:

Date/ CUES NE NURSING DIAGNOSIS OBJECTIVE OF NURSING EVALUATION

Time ED CARE INTERVENTIONS
O: Risk for injury: Hemorrhage Within my 4 hours Assess for signs
-Weakness related to altered clotting factor. span of care, patient and symptoms of
and will free from injury as G.I bleeding.
Irritability. R: This infectious evidence by; Check for
− Restlessnes disease is manifested by a secretions.
s. Observe color “Goal Met”
sudden onset of fever,with a. Maintain vital
severe headache, muscle and signs within the and consistency After my 8 hours span of care,
- IVF: joint pains (myalgias and normal range of stools or
D5LR 80cc/hr arthralgias— BP: 90/70mmHg – vomitus. patient was free from injury as
followed by severe pain gives it the name 130/90mmHg R: The G.I tract
evidenced by:
D5NSS (esophagus and
breakbone fever or bonecrusher Temp: 36.5-37.5
disease) and rashes and CR: 60-100bpm rectum) is the a. vital signs within normal
VS: most usual
usually appears first on the PR: 60-100bpm range:
source of
lower limbs and the chest. There RR: 16-20cpm bleeding of its
may also be gastritis and some mucosal
times bleeding. b. Absence of Fragility. BP :120/90 mmHg
haemorrhage in 2. Observe for Temp : 36 C
the diferetn presence of RR : 18 cpm
sites such as petechiae, PR : 75 bpm
bleeding in the ecchymosis, CR : 78 bpm
nose, gums, bleeding from one
ears, hematuria more sites.
or hematemesis. b. no any evident of hemmorhage
R: Sub-acute
disseminated noted.
intravascular
coagulation
(DIC) may
develop
secondary to
altered clotting
factors.
3. Monitor pulse,
Blood pressure.
R: An increase in
pulse with