Cues Nursing Analysis Goals and Intervention Rationale Evaluation

Diagnosis Objectives
Subjective: Risk for a. Health Goal (Long 1. Monitor signs 1. Platelet Was the goal
Injury: implications: Term): Within 2-3 of decreased decline is a met, unmet,
·Client’s Bleeding Platelets play an days of nursing platelets sign of blood or partially
guardian related to important role in clotting interventions, accompanied vessel leakage, met?
reported decreased and bleeding. In people patient will by clinical which at some
moderate pain platelet count with a low platelet count, maintain reduced signs. stage may Met ____
in the bleeding is more likely to risk of bleeding as cause clinical Unmet ____
abdominal area occur, even after a slight evidence by normal 2. Monitor signs such as Partially met
on the third day injury. Low platelet platelet count and platelets every epistaxis, _____
of admission count may result in absence of any day petechia.
spontaneous bleeding. signs of bleeding
(Merck Manual, 2009, (bruises/petechiae). 3. Instruct the 2. With the
Objective: Sec. 3, chapter 49) patient to a lot platelets being
·CBC Result: b. Situational
Objective (Short of rest. (bed monitored on
analysis: Term): Within the rest). daily basis, it
RBC: Immediate shift, patient’s risk
cause: can be seen the
4.53x10^12/L Client experienced
for bleeding is level of
Hemoglobin: continuous dengue fever
reduced as 4. Provide vascular leak
116.0g/L prior to admission evidenced by vital information to and possible
Platelet signs within clients and bleeding
count: Root cause: Client’s normal range, families to experienced
65x10^g/L immune system was absence of report any by the patient.
compromised due to narrowed pulse signs of
·VS fever pressure and bleeding such 3. Patient activity
T: 36.1 celsius diminished signs of as: can lead to
BP: 110/90 bleeding hematemesis, uncontrolled
mm/hg (bruises/petechiae, melena, bleeding.
PR: 80 bpm epistaxis, bleeding epistaxis.
RR: 20 cycles gums, abdominal 4. The
pain, hematemesis, involvement
of patients and
hematuria, families may
melena). help to early
treatment if
there is
bleeding.