NURSING CARE PLAN

ASSESSMENT
Subjective: “Dumudugo ang ilong ng anak ko” (My son’s nose is bleeding) as verbalized by the mother. Objective: •

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.

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

• •

Weakness and irritability. Restlessness. V/S taken as follows: T: 38 P: 55 R: 18

Monitor pulse, Blood pressure.

Note changes in mentation and level of consciousness.

Use small needles for injections. reducing risk for bleeding and hematoma. and forceful nose blowing. potentiating risk of hemorrhage. Recommend avoidance of aspirin containing products. avoiding straining for stool. • • • • • Rectal and esophageal vessels are most vulnerable to rupture. • . Indicators of anemia. Prolongs coagulation. Encourage use of soft toothbrush.• Avoid rectal temperature. minimal trauma can cause mucosal bleeding. active bleeding. In the presence of clotting factor disturbances. Apply pressure to venipuncture sites for longer than usual. Minimizes damage to tissues. • • Collaborative: • Monitor Hb and Hct and clotting factors. be gentle with GI tube insertions. or impending complications.

Sign up to vote on this title
UsefulNot useful

Master Your Semester with Scribd & The New York Times

Special offer: Get 4 months of Scribd and The New York Times for just $1.87 per week!

Master Your Semester with a Special Offer from Scribd & The New York Times