NURSING CARE PLAN

Name of Patient: Mangku Kowlam Date Admitted: May 7, 2022 Chief Complaint: Hepatic Failure and Hypotension Case Number: 3

Age: 14 years old Gender: Male Civil Status: Single Address: Los Banos Laoang AP: Jonathan Mercado Raul Sy
 NURSING GOALS AND
ASSESSMENT RATIONALE NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES
Subjective Data: Risk for bleeding in Clotting factors are Short Term Goals and Independent: Independent: Short term Goal and
relation to abnormal evident in patient with Objectives: 1. Establish patient rapport 1. This is to encourage Objectives:
-------- blood profiles history of liver disease. patient active cooperation
evident in altered Liver plays viral role in Within 24 hours of providing and trust Within 24 hours of patient
nursing care, the patient will: 2. Reviewing patient history
Objective Data: prothrombin time, clotting process, thus 2. Review patient’s health history care, desired outcomes are
 Be free from risk of
and clotting factor liver diseases are for risk factors that can be provides foundation as to met and patient is now :
severe bleeding
Coagulation Factors: deficiencies. invariably associated associated with risk of bleeding what appropriate nursing  Free from risk of
 Achieve normal
with coagulation coagulation factors intervention should be severe bleeding
disorders due to namely; done to the patient  Achieve normal
 prothrombin time
multiple causes such as Prothrombin time, 3. Monitor patients vital signs 3. Hypotension is usually coagulation factors
24.4 sec
decrease in synthesis of APTT, INR, especially blood pressure are compensatory with laboratory
 APTT 52 Firbinogen, and
clotting and inhibitor mechanisms and usually values at normal
 INR 2.4 clotting factor V
factors, decrease 4. Evaluate patients medications noted with bleeding range
 Fibrinogen 412 activity, VII, and V
clearance of activated 4. Reviewing patient
mg/dL, leiden.
factor, and many more. medications provides Long Term Goals and
 Factor V activity knowledge to nursing
Long Term Goals and Objectives:
39% (normal intervention should be
Objectives:
range 70%- performed as drugs that Within 5 days of patient
120%) Within 5 days of nursing interfere with clotting care, the desired goals are
 Factor VII 19% intervention, the patient will: mechanisms or platelet now met and the patient is:
(normal range  Verbalize measures activity increase risk for
to prevent bleeding  Able to verbalize
70%-130%) bleeding enabling
and recognizes signs measures to prevent
 Factor V Leiden - preparation for adverse
of bleeding that bleeding and
absent effects and complications
need to be reported recognizes signs of
immediately to 5. Review laboratory results for 5. The laboratory tests bleeding that need
parents. coagulation status provide important to be reported
information about immediately to
patient’s blood parents.
coagulation status and
enables assessment of
potential bleeding.
6. Assess skin and mucosa 6. Patients with impaired
membrane for signs of bruising clotting factor activity
and hematoma formation may experience bleeding
into tissues
7. Monitor hematocrit and 7. Decreased hematocrit and
haemoglobin haemoglobin levels may
be an early indicator of
bleeding, if not visible
8. Educate the at-risk patient about 8. Information about
precautionary measures to precautionary measure
prevent tissue trauma such as would lessen the risk for
brushing teeth using soft-bristled bleeding
brush and avoiding toothpicks