Patient’s initials: A. D. A.

Sex: Female
Age: 12
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Risk for hemorrhage -After 3 hours of -Assess the signs and -The GI tract is the most -After 3 hours of
related to altered nursing interventions, symptoms of GI usual source of bleeding nursing
clotting factor the client will be able bleeding. Check for of its mucosal fragility interventions, the
to demonstrate secretions. Observe color client is able to
behaviors that reduce and consistency of stools demonstrate
the risk of bleeding. or vomitus. behaviors that
Obejective: -Observe for presence of -Sub-acute disseminated reduce the risk of
-Weakness and petichiae, ecchymosis, intravascular coagulation bleeding.
irritability bleeding from one more may develop secondary
-Restlessness sites to altered clotting factor.
-V/S taken as -Monitor pulse, BP -an increase in pulse with
follows: decrease BP can indicate
T- 38.1 C loss of circulating blood
P- 102 bpm volume.
R- 22 cpm -Note changes in level of -Changes may indicate
BP- 90/60 mmHg consciousness. cerebral perfusion
problems.
-Encourage use of soft -Minimal trauma can
toothbrush. Avoid cause mucosal bleeding
straining in stool, and
forceful nose blowing.
-Use small needles for -Minimize damage to
injections. Apply tissues, reduce risk for
pressure to venipuncture bleeding and hematoma.
sites for longer than
usual.
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective Tissue -After 4 hours of -Encourage patient to -To help elevate After 4 hours of
-Dizziness Perfusion r/t nursing intervention, take iron supplements hemoglobin and nursing intervention,
-Abdominal pain Decreased hemoglobin the client will be able and eat foods rich in hematocrit levels the client is able to
-Muscle weakness iron. -To promote circulation
concentration in blood to demonstrate demonstrate different
-Elevate head of bed to and venous drainage.
AEB low hemoglobin different ways to about 10 degrees. ways to improve
-To avoid increased
concentration, pallor improve blood -Discourage strenuous blood oxygenation
oxygen demand.
and dizziness, and oxygenation and activities. and circulation.
muscle weakness. circulation. -To help client
Objective: -Provide health teaching understand his health
-Pallor regarding DHF and condition.
-Hemoglobin = 63 Typhoid Ilietis
g/L -Provide health teaching -To maintain compliance
-Hematocrit = 0.19 on drugs being taken.
to meds.
L/L 1.
-Serve as basis for any
-Monitor vital signs.
alteration in system
functions.

- Encourage early - Enhances venous

ambulation when return.
possible.

-Monitor lab studies -Aids in establishing

( Hb,Hct, RBC count) blood replacement needs
& monitoring
effectiveness of therapy.
 Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Acute pain r/t tissue After 8 hours of -Monitor v/s and check -Alterations from normal After 8 hours of
-“ang sakit po ng trauma s/t post nurse-client dressing of affected may be signs of infection. nurse-client
dibdib ko” as abdominal surgery intervention the surgical site. Moistened dressings are intervention the
verbalized by the AEB reported pain patient will be able to favorable site for patient is be able
patient. with a scale of 8, sleep verbalize minimized microorganisms.
disturbance & guarded or controlled feeling -Assess for signs of pain, -To aid in evaluating to verbalize
behavior on affected of pain. location, and intensity and need for proper minimized or
area. use of pain scale (0-10) and intervention. Continued controlled feeling
evaluate characteristics of pain may indicate of pain.
pain. developing complication.
Objective:: -Inform client to avoid -Prevent from
-Guarded behavior weight bearing until complications on the
-Restless allowed. incision site.
-Pain Scale= 7 -Encourage diversional -Allow the muscle to
(10 is highest) activities and use of relax and serve as
-BP=90.70 relaxation exercises such as diversion from pain.
focused breathing.
-Encourage adequate rest -Promote healing by
and sleep. reducing basal metabolic
rate and allowing oxygen
& nutrients to be utilized
for tissue regeneration
-Provide comfort measures -Reduce swelling &
such as back rub & change prevent stiffnes.
of position. Decreased lung capacity
& decreased cough
efficiency are
predisposing factors of
respiratory infection.