Assessment Nursing Planning Implementation Rationale Expected

Diagnosis Outcome
Subjective: Risk for After 8 Independent: Hypotension  After 8
The Patient is bleeding hours of -Monitor and hours of
having a 4 related to nursing patient’s vital tachycardia nursing
days of high thrombocyt interventio signs, especially are initial interventi
fever ranging openia n Patient BP and HR. compensator on goal
from 38.6 to does not Look for signs of y and
40 C, experience orthostatic hypot mechanisms objective
accompanied bleeding ension. 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. 
-Heat loss by
V/S:  -Provide Tepid means of
Temp 39.4 C, sponge bath radition and
BP 100/70, conduction
RR:21,
PR 122. 
Wt: 62Kg.  -To reduce
-Promote metabolic
surface cooling demands of
by means of oxygen
undressing consumption

-To know if
-Maintain bed the patient’s
rest or minimize temperature
movement went normal

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

Dependent: - For patients

-Administering IV with a high
fluids and body
antipyretic drugs. temperature,
fluid
supplementati
on is essential.
A specific
medicine is
used to
reduce a
patient's body
temperature