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Student’s Name: Ramos, Shelly Mae A.

Date: January 31,2012
Patient’s Initials: L.T.

NURSING CARE PLAN

ASSESSMENT DIAGNOSI BACKGROU PLANNIN INTERVENTIO RATIONAL EVALUATION
S ND G N E
KNOWLEDG
E
Subjective: Risk for Blood is a After 4 INDEPENDENT: Goal was met.
bleeding specialized hours of Assessed vital >To After 4 hours of
related to fluid in rendering signs, including determine if rendering
human body blood pressure, intravascula nursing care, the
Objective: decrease nursing
that delivers pulse and r deficits patient’s
thrombocyt necessary intervention respirations exists. laboratory result
e count substances , the patient displays
secondary such as will be able Noted client increase from
to Dengue nutrients and to: report of pain in >Can help previous….
Febrile oxygen to the specific areas, identify
Syndrome cells. The whether pain is bleeding
>Be free of
body uses increasing, into tissues,
as signs of
platelets diffuse or organs, or
manifested (thrombocyte bleeding localize body
by ………… s) to form a such as cavities
blood clot and hematuria, Assessed skin
prevent blood hemoptysis color and >Changes of
loss. Thus, a or moisture, these signs
decrease in urinary output may be
hematemesi
platelet count and level of indicative of
prevents s. consciousness decrease in
formation of circulating
clots which >Display blood
leads to laboratory volume
hemorrhage Assessed for
results for

> Rectal and esophageal vessels are Encouraged use most of vulnerable soft toothbrush.T. ecchymosis. the range for Observe color most usual individual. NURSING CARE PLAN and may clotting signs >The G. Shelly Mae A. and within bleeding. to rupture. and consistency source of of stools or bleeding of vomitus. be gentle with GI tube insertions. boundaries of the extent Avoided rectal temperature. presence of petechiae.2012 Patient’s Initials: L. >To bleeding from evaluate and one mark more sites.I result in both times and and symptoms tract internal & factors of (esophagus external G. Check for rectum) is normal secretions. its mucosal Observed for fragility.Student’s Name: Ramos. avoiding straining >To reduce . Date: January 31.I bleeding.

Maintained a safe envirinment >Reduces DEPENDENT accidental Recommended injury avoidance of aspirin containing >Prolongs products.Student’s Name: Ramos. and risk of forceful nose mucosal blowing. Shelly Mae A. risk for bleeding and Monitored Hb hematoma. of . sites for longer reducing than usual. bleeding. Date: January 31. NURSING CARE PLAN for stool. potentiating COLLABORATIV risk E of Used small hemorrhage. needles for injections and Applied >Minimizes pressure to damage to venipuncture tissues. coagulation.T. and Hct and clotting >Indicators factors.2012 Patient’s Initials: L.

active bleeding. .2012 Patient’s Initials: L. or impending complication s.Student’s Name: Ramos. Date: January 31. Shelly Mae A. NURSING CARE PLAN anemia.T.