Name: Age: Sex: Date/ Time CUES O: -Weakness

and Irritability. − Restlessnes s.

Ward: San Lorenzo Ward Room #: Hospital: NE ED NURSING DIAGNOSIS Risk for injury: Hemorrhage related to altered clotting factor. R: 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. OBJECTIVE OF CARE Within my 4 hours span of care, patient will free from injury as evidence by; a. Maintain vital signs within the normal range BP: 90/70mmHg – 130/90mmHg Temp: 36.5-37.5 CR: 60-100bpm PR: 60-100bpm RR: 16-20cpm b. Absence of haemorrhage in the diferetn sites such as bleeding in the nose, gums, ears, hematuria or hematemesis. NURSING INTERVENTIONS
Assess for signs and symptoms of G.I bleeding. Check for secretions. Observe color and consistency of stools or vomitus. R: The G.I tract (esophagus and rectum) is the most usual source of bleeding of its mucosal Fragility. 2. Observe for presence of petechiae, ecchymosis, bleeding from one more sites. R: Sub-acute disseminated intravascular coagulation (DIC) may develop secondary to altered clotting factors. 3. Monitor pulse, Blood pressure. R: An increase in pulse with

AP: Diagnosis:

EVALUATION

“Goal Met” After my 8 hours span of care, patient was free from injury as evidenced by: a. vital signs within normal range: BP :120/90 mmHg Temp : 36 C RR : 18 cpm PR : 75 bpm CR : 78 bpm b. no any evident of hemmorhage noted.

- IVF: D5LR 80cc/hr followed by D5NSS VS:

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