ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

Subjective:
Basta po dinugo po
akong maray tas grabe
po su raut nung pagmati
ko nikadto as
verbalized by the client.

Risk for bleeding

related to active fluid
volume loss-hemorrhage as
evidenced by the
presence of signs
and symptoms

Short term goal:

After 2 days of
nursing intervention,
the bleeding of the
client will decrease

1. Monitor Vital
signs. Compare
clients normal and
previous readings.
2. Assess level of
weakness.
3. Check the patency
of IVF and BTs
4. Monitor
continuation of
bleeding through
feces
5. Provide comfort
6. Educate about the
bleeding

1. To have baseline
data of severity of
the alteration.
2. To know signs
of/involvement of
abdomen
functioning.
3. To make sure
replenishment of
blood and blood
products is on
desired or
therapeutic level.
4. To have an idea
on the state of
bleeding
5. Promotes
relaxation

Administer meds as
prescribed by the
physician

To maintain
acceptable level of
pain

Objective:
Pale skin
(+) Bleeding
Asking for assistance
Weakness
Nausea and vomiting

Long term goal:

After 3 days of
nursing intervention,
the client will be
educated and will be
relieved or
controlled.

RATIONALE

EVALUATION

After nursing
interventions:
The bleeding
decreased
The client was
educated
The client is relieved
and controlled.
Goals are met