NURSING PROBLEM with CUES

NURSING DIAGNOSIS with RATIONALE (with reference)

(SMART) GOALS/ OBJECTIVES

NURSING INTERVENTIONS

RATIONALE FOR INTERVENTIONS

EXPECTED OUTCOMES

EVALUATION

2.Risk for Bleeding Date: Nov. 27, 2009 Subjective: Ang dami niyang pasa at rashes as verbalized by the patients mother. Objective: Petechial Rashes Ecchymoses Hematology: -Platelet: 6 103/UL -Hgb- 6.7 -Hct- 0.20 V/S as follows: -T: 39.3 C -HR: 137 bpm -RR: 40 bpm -BP: 100/90mmHg

High Risk for Injury: Short term goal: 1. Assessed and Bleeding related to monitored vital signs. decreased platelet count Within the shift, patients risk for Rationale: bleeding is reduced as evidenced by vital Platelets play an signs within normal important role in range, absence of 2. Assessed for any clotting and bleeding. narrowed pulse signs of bleeding. In people with a low pressure and platelet count, bleeding diminished signs of is more likely to occur, bleeding (bruises/ even after a slight petechiae, epistaxis, injury. Low platelet bleeding gums, count may result in abdominal pain, spontaneous bleeding. hematemesis, (Merck Manual, 2009, hematuria, melena). Sec. 3, chapter 49) Long term goal: 3. Monitored platelet count. Within 2-3 days of nursing interventions, patient will maintain 4. Avoided IV /SC reduced risk of injections and rectal bleeding as evidence procedures (such as by normal platelet enemas and rectal count and absence of temperature taking) any signs of bleeding as necessary. (bruises/petechiae)

1. Increased heart rate 1. Patient

will reduce risk of and orthostatic bleeding. changes accompany rd bleeding. (NCP. 3 ed., Schroeder & 2. Patient will be free from any Jones, 1994, p 389) injury. 2. Bleeding may be obvious (bruises/ petechiae epistaxis, bleeding gums, abdominal pain, hematemesis, melena, hematuria). (NCP. 3rd ed., Schroeder & Jones, 1994, p 389, 422) 3. Spontaneous bleeding can occur at platelet count <50,000/mm3

Short goal:

term

4.

Can stimulate bleeding; to reduce unnecessary trauma. (NCP. 3rd ed., Mc McCarthy & Schroeder, 1994, p 383, 423)

Goal partially met. After 8 hours shift, patient risk for bleeding was reduced as evidenced by vital signs within normal range, absence of narrowed pulse pressure and diminished signs of bleeding (epistaxis, hematemesis, hematuria, melena) Nov. 29, 2009 V/S as follows: BP 100/70 mmHg T 36. 1 C HR 119 bpm RR 30 bpm

5. Placed sign patients bed.

over

5. As

6. Maintained environment patient.

safe for 6. To prevent falls/ injury.(NCP. 3rd ed., Schroeder, 1994, p 422) 7. Transfused PRBC as prescribed. 7. To restore Hgb/Hct level and to replace blood lost. (NCP. 3rd ed., Schroeder & Jones, 1994, p 389) 8. Communicated anticipated need for 8. To assure availability platelet support to and readiness of transfusion center. platelets when needed. (NCP. 3rd ed., Schroeder, 1994, p 406)

reminder of bleeding precautions and to apply pressure after venipunctures. (NCP. 3rd ed., Puzas, 1994, p 425)

Long goal:

term

Goal partially met. After 3 days of nursing interventions, patient maintained reduced risk for bleeding as evidenced by diminished signs of bleeding (bruises/petechi ae). Dec. 3, 2009 Hematology: Platelet = 10 x 103/UL Hgb- 0.28 Hct- 0.96