NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: This infectious After 1 hr. Of • Assess for • The G.I tract After 1 hr. Of
disease is nursing signs and (esophagus and nursing
“Hindi na ako Risk for manifested by a interventions, the symptoms of rectum) is the interventions, the
nahihilo, pero yung hemorrhage sudden onset of client will be able G.I bleeding. most usual client was able to
result po ng related to alter fever, with severe to demonstrate Check for source of demonstrate
platelet ko ay 81. clotting factor. headache, muscle behaviors that secretions. bleeding of its behaviors that
Sabi ng doctor and joint pains reduce the risk for Observe color mucosal reduce the risk for
mababa pa daw po (myalgias and bleeding. and fragility. bleeding
yun” arthralgias—severe consistency of
pain gives it the stools or
name break-bone vomitus.
Objective: fever or • Observe for • Sub-acute
HHP result: bonecrusher presence of disseminated
Hemoglobin: 128 disease) and rashes petechiae, intravascular
Hemetocrit: 0.39 and usually appears ecchymosis, coagulation
Platelet: 81 first on the lower bleeding from (DIC) may
limbs and the one more sites. develop
chest. There may secondary to
also be gastritis altered
and some times clotting
bleeding factors.
• Monitor pulse, • An increase in
Blood pressure. pulse with
decreased
Blood pressure
can indicate
loss of
circulating
blood volume.
• Reinstruct • To monitor
client that may presence of GI
have diet as bleeding
tolerated but
 not to eat dark
color foods.
• Note changes • Changes may
in mentation indicate
and level of cerebral
consciousness. perfusion
secondary to
hypovolemia,
hypoxemia.
• Encourage use • In the
of soft presence of
toothbrush, clotting factor
avoiding disturbances,
straining for minimal trauma
stool, and can cause
forceful nose mucosal
blowing. bleeding.
• Use small • Minimizes
needles for damage to
injections. tissues,
Apply pressure reducing risk
to venipuncture for bleeding
sites for and hematoma.
longer than
usual.
• Recommend • Prolongs
avoidance of coagulation,
aspirin potentiating
containing risk of
products. hemorrhage.

Collaborative: • Indicators of
Monitor Hb and anemia, active
Hct and clotting bleeding, or
factors. impending
complications.