NURSING CARE PLAN

ASSESSMENT
Subjective:
Dumudugo ang
ilong ng anak ko
(My sons nose is
bleeding) as
verbalized by the
mother.
Objective:

Weakness and
irritability.

Restlessness.

V/S taken as
follows:
T: 38
P: 55
R: 18

DIAGNOSIS

Injury, risk for

hemorrhage
related to
altered clotting
factor.

INFERENCE

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

PLANNING

After 1 hr. Of
nursing
interventions,
the client will
be able to
demonstrate
behaviors
that reduce
the risk for
bleeding.

INTERVENTION
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,
ecchymosis,
bleeding from one
more sites.

RATIONALE

The G.I tract

(esophagus and
rectum) is the
most usual
source of
bleeding of its
mucosal
fragility.

Sub-acute
disseminated
intravascular
coagulation
(DIC) may
develop
secondary to
altered clotting
factors.
An increase in
pulse with
decreased
Blood pressure
can indicate
loss of
circulating
blood volume.
Changes may
indicate
cerebral
perfusion
secondary to
hypovolemia,
hypoxemia.

Monitor pulse,
Blood pressure.

Note changes in
mentation and
level of
consciousness.

EVALUATION

After 1 hr. Of
nursing
interventions,
the client
was able to
demonstrate
behaviors
that reduce
the risk for
bleeding.

Avoid rectal
temperature, be
gentle with GI
tube insertions.

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

Use small
needles for
injections. Apply
pressure to
venipuncture
sites for longer
than usual.

Recommend
avoidance of
aspirin containing
products.

Prolongs
coagulation,
potentiating risk
of hemorrhage.

Indicators of
anemia, active
bleeding, or
impending
complications.

Collaborative:
Monitor Hb and
Hct and clotting
factors.

Rectal and
esophageal
vessels are
most vulnerable
to rupture.
In the presence
of clotting factor
disturbances,
minimal trauma
can cause
mucosal
bleeding.
Minimizes
damage to
tissues,
reducing risk for
bleeding and
hematoma.