Assessment Nursing Planning Implementation Rationale Expected

Diagnosis Outcome
Subjective: Risk for After 8 -Monitor Hypotension  After 8
The Patient is bleeding hours of patient’s vital and hours of
having a 4 related to nursing signs, especially tachycardia nursing
days of high thrombocyt interventio BP and HR. are initial interventi
fever ranging openia n Patient Look for signs of compensator on goal
from 38.6 to does not orthostatic hypot y and
40 C, experience ension. mechanisms objective
accompanied bleeding usually noted s was
by epigastric as with met by
pain, vomiting, evidenced bleeding. normaliz
and tolerable by Orthostasis ed
headache. normal blo (a drip of 20 the blood
od mm Hg in pressure,
Objective: pressure, systolic BP stable
-Congenital stable or 10 mm Hg hematocr
Heart Dse in hematocrit in diastolic it and
2017 and BP when hemoglo
Laboratory hemoglobi changing bin levels
-Low Platelet n levels from supine t
count of and o sitting
67,000; desired position)
while U/A ranges for indicates
reveals RBC coagulatio reduced
of 1-3/hpf, Pus n profiles. circulating
Cells of 10- fluids.
12/hpf. 
-Provide Tepid -Heat loss by
V/S:  sponge bath means of
Temp 39.4 C, radition and
BP 100/70, conduction
RR:21,
PR 122. 
Wt: 62Kg.  -Promote -To reduce
surface cooling metabolic
by means of demands of
undressing oxygen
consumption

-Maintain bed -To know if

rest or minimize the patient’s
movement temperature
went normal
 -Strictly monitor -To prevent
temperature dehydration

-Monitor - When
hematocrit (Hct) bleeding is
and hemoglobin not visible,
(Hgb) decreased
Hgb and Hct
levels may
be an early
indicator of
bleeding.