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Objective Cues: • Bloody discharges coming out of the incision area Fresh blood coming out Bright red discharges
Nursing Diagnosis Risk for bleeding related to posoperative incision located at the inguinal area
Scientific Analysis At risk for decrease in blood volume that may compromise health.
Planning Short term goal: Psychomotor: After 10 minutes of nursing care, client will be able to be aware of the signs and symptoms for bleeding by screening of the risk factors of bleeding Affective: After 10 minutes of nursing care, client will state changes in thinking of the risk factors of bleeding after the procedure Cognitive: After 10 min. of nursing care client will able to identify the risk situations for bleeding after the procedure (e.g. trauma or injury)
Intervention Independent: Screen the client for risk for bleeding factors Monitor client for signs and symptoms of bleeding (e.g. tachycardia, pallor, blood at the dressing) Monitor the incision site for any signs of bleeding Instruct client to observe any bloody discharges after the procedure Obtain Baseline Vital Signs
Evaluation Goal: Met
To prevent any risk factors for bleeding Assess any signs and symptoms of bleeding after the procedure
After 10 minutes of nursing care, client has able to understand of the risk factors in bleeding after the procedure.
To observe incision site as having bleeding tendency To make the client aware of the discharges which may contribute to bleeding To have a baseline data in cases of bleeding