ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION Assess and Monitor vital signs

RATIONALE Increase heart rate and orthostatic changes company bleeding Bleeding may be obvious ( petechiae, epistaxiss, bleeding gums, hematoma, melena ) Spontaneous bleeding can occur at platelet count <50,000 /mm3 As reminder of bleeding precautions and to apply pressure to venipunctures. To prevent falls and injury

EVALUATION

Subjective: ang dami kong pasa at rashes as verbalized by the patient.

Risk for bleeding related to decreased platelets count

Objective: o o o Petechial Rashes Hematoma Hematology Platelet: 120 Hgb: 172 Hct: 0.50 Vital signs as follows Temp.: 38.3c HR: 137bpm RR: 40bpm BP: 130/100

After 6 hours of nursing intervention, patients risk for bleeding is reduced as evidenced by vital signs within normal range, absence of narrowed pulse pressure and diminished signs of bleeding ( petechiae, epistaxiss, bleeding gums, hematoma, melena )

Assess for any sign of bleeding

Monitored platelet count

Goal partially met. After 6 hours of nursing intervention, patients risk for bleeding is reduced as evidenced by vital signs within normal range, absence of narrowed pulse pressure and diminished signs of bleeding ( petechiae, epistaxiss, bleeding gums, hematoma, melena )

Placed sign over patients bed

Maintained safe environment for patient Transfused PRBC as prescribed.

To restore Hgb/Hct level and to replaced blood loss

 Communicated anticipated need for platelet support to transfusion center

To assure availability and readiness of plateless when needed