Patient’s Initial: R.

M NURSING CARE PLAN STUDENT NURSE: DIESTRO, ANGELA MAE BSN 2B

Cues Nursing diagnosis Rationale Goals and Nursing Rationale Evaluation

outcomes criteria intervention

Objective: Risk for bleeding Thrombocytopeni After shift the INDEPENDENT An increase in Patient’s did not
related to a is a condition in patient’s a. Assessment temperature may experience
- Warm to touch decreased which you have a temperature will be present in a bleeding as
- Febrile platelet count low blood platelet reduce to normal - Monitor Vital patient with evidence by
- Visible skin rashes count to the point range signs Dengue normal blood
- Poor appetite that it won’t able Hemorrhagic pressure, stable
- Lack of energy to stop bleeding - Report pain is Fever haematocrit and
- Chest X - ray internally. relieved or - Monitor food haemoglobin
revealed controlled intake and - Monitoring food levels and desired
consolidation at Reference observe appetite intake is ranges for
the bibasal area Mayoclinic.org - Patient displays important coagulation
- Laboratory laboratory results especially if the profiles.
results; within normal b. Health patient have poor
 Below range for Teaching appetite Patients remained
normal individuals free of infection,
hemoglobi - Risk of A situation where - Instruct patient - Immediate as evidenced by
n Value Imbalance individuals who - Patient displays to report response to normal vital signs
(9g/dl) Nutrition: less are at risk of improved temperature reports of and absence of
 Normal than body weight loss wellbeing such as changes temperature signs and
hematocrit requirements associated with baseline levels for change can result symptoms of
Value related to poor inadequate input, pulse, BP, - Educate the to immediate infection.
(48%) appetite and or metabolism of respirations patient and family action
 Below fatigue. nutrients is not members about
normal adequate for - Patient rashes signs of bleeding - Early evaluation - Client
WBC Value metabolic needs. and body malaise that need to be and treatment of communication
(3,000 visibility ranged reported to a bleeding by a verbally improves
cells/mm3) Reference down to non- health care health care
 Very Low Nurseslabs.com existent. provider. provider reduce
Actual the risk for - Patient displays
Platelet complications improvement in
Count from blood loss. appetite and has a
Patient’s Initial: R.M NURSING CARE PLAN STUDENT NURSE: DIESTRO, ANGELA MAE BSN 2B

Value (80 - Communication proper nutritional

cells/mm3) verbally improves. 2. DEPENDENT status

- Maintain fluid - Prescribe - To ensure the

volume at a medication and effectiveness of
Subjective: functional level evaluate the medication - Client
effectiveness for the client demonstrates
“mainit akon - Be afebrile and behaviors and
pamatyagan” free from other - Administer lifestyle changes
signs of infection vitamins and that regains and
My body feels hot minerals if maintain
ordered - Vitamins and appropriate
- Patient displays minerals are nutrition intake.
improvement in 3. needed to
appetite. COLLABORATIVE maintain
metabolic - Client showed
After 1-2 days of - Refer to the functioning no signs of fatigue
nursing physician if the
interventions temperature is
client will be able still higher than - To monitor the
to demonstrate normal patient condition GOAL MET
behaviors,
lifestyle changes
to regain and
maintain - Consult dietician - Dieticians have a
appropriate for further greater
nutrition intake. assessment and understanding of
recommendations the nutritional
regarding food value of foods
- Client shows no preferences and and may be
signs of fatigue nutritional helpful in
support. assessing specific
ethnic or cultural
foods.
Patient’s Initial: R.M NURSING CARE PLAN STUDENT NURSE: DIESTRO, ANGELA MAE BSN 2B

STUDENT NURSE: DIESTRO, ANGELA MAE BSN 2 B