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Nursing Care Plan

On Risk for Bleeding


By: Cazze Lynn Sunio
BSN 2B
Name of Patient : R.C.
Age/Sex : 20/Female
Rm. Bed # : DR4-3
Reason For Admission: Fever and Rashes
Attending Physicians: Dr. Garado, Dr. Arao, Dr.
Nazareno
Diagnosis: G-1, AOG: 29 1/7
Date and Time: August 20, 2014 @ 9 am

CUES:
Subjective: Miss paki-tawag daw si Doc. Akung
kugmo lagi kay puro dugo.

Objective:
withCC of fever and rashes.
With associate headache andjoint pain.

With pink palpebral conjunctiva.
With (+) loss of appetite.
With observed weakness / restlessness
With observed flushing of face, cheeks and lips.
With hemoglobin count of 104 (normal: 120-
160)
With WBC count of 18.1 (normal: 5.0-10.0)
With platelet count of 17
With (+) Uterine contractions every 15 mins.
With VS of:
T=35.8 degree celcius
CR=107 bpm
PR=100 bpm
RR=33 bpm
BP=90/70 mmhg
FHT=126 bpm

Need:
Health Perception-Health Management Pattern

Nursing Diagnosis:
Injury, risk for bleeding r/t altered clotting
factor aeb decreased platelet and hemoglobin
count secondary to dengue hemmorhagic fever.
R: this disease is manifested by a sudden onset
of fever, headache, joint/muscle pain, nausea
and vommiting and decreased in appetite.
Rashes and ecchymosis can be seen in the acute
phase. There may also be gastritis and bleeding
because of altered clotting factors due to low
platelet count (thrombocypenia) that may lead
to worsening cases of DHF.
Objective of Care:
After 6 hrs. of nursing interventions, the pt. will
be able to demonstrate behaviors that reduces
the risk for bleeding aeb:
a. Gaining good appetite
b. Increase in fluid intake
c. Avoidane of dark colored foods/fluids and
eating food rich in vit. C
d. Eradication of weakness/restlessness
Nursing Interventions:
1. Establish rapport and good working condition
with the patient. R: to gain patients trust and
cooperation.
2. Assess for signs and symptoms of G.I. bleeding
/nosebleeding. Note for color of stool,
vomitus and urine. R: the G.I. track (esophagus
& rectum) is the most usual source of bleeding
due to its mucosal fragility.

3. Observe for presence of petechiae, ecchymosis,
bleeding from one or more sites. R: Sub-acute
disseminated intravascular coagulation (DIC) may
develop sec. to altered clotting factors.
4. Monitor VS especially Pulse and BP. R: an increase
in pulse with decreased blood pressure can indicate
loss of circulating blood volume.

5. Encourage use of soft toothbrush, avoid straining for
stool, and forceful nose blowing. R: in the presence of
clotting factor disturbances, minimal trauma can cause
mucosal bleeding.
6. Avoid dark colored foods/fluids. R: dark colored
foods/fluids may mask bleeding.
7. Encourage patient to eat food rich in vit. C. R: to boost
body resistance to infections that may lead to further
complications.

8. Encourage the patient to rest more. R: rest promotes
body recovery from aches and pains.
9. Increase in fluid intake as indicated. R: body needs 3-
3.5L of water daily as the body has sensible & insensible
water losses. More water intake surely aids in the
recovery of the patient and prevents dehydration.
10. Monitor Hb, Hct, WBC and platelet count every 12
hrs. R: These are indicators of anemia, active
bleeding/impending complications.
Evaluation:
August 20, 2014@3pm.
Goal partially met. After 6 hrs. of nursing interventions,
the patient was able to demonstrate behavior that
reduced the risk for bleeding aeb:
a. The patient was still observed to have loss of
appetite.
b. The patients total fluid intake @ the end of the shift
is 1,260 cc
c. The patient only eats rice & soup, only drinks water
and apple juice.
d. The patient was able to rest/sleep.