NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: • Injury, risk for • This infectious • After 1 hr. Of • Assess for signs • The G.I tract • After 1 hr.
hemorrhage disease is nursing and symptoms of (esophagus and Of nursing
“Bigla na lang related to manifested by interventions, G.I bleeding. rectum) is the intervention
dumugo ang ilong altered clotting a sudden the client will Check for most usual s, the client
ng anak ko” as factor. onset of fever, be able secretions. source of will be able
verbalized by the with severe demonstrate Observe color bleeding of its demonstrate
mother. headache, behaviors and consistency mucosal behaviors
muscle and that reduces of stools or fragility. that reduces
Objective: joint pains the risk for vomitus. the risk for
(myalgias and bleeding. • Observe for • Sub-acute bleeding.
• Weakness and arthralgias— presence of disseminated
irritability. severe pain petechiae, intravascular
gives it the ecchymosis, coagulation
• Restlessness. name break- bleeding from one (DIC) may
bone fever or more sites. develop
• V/S taken as bonecrusher secondary to
follows: disease) and altered clotting
rashes and factors.
T: 37.5 usually • Monitor pulse, • An increase in
P: 55 appears first Blood pressure. pulse with
R: 18 on the lower decreased
Bp: 90/70 limbs and the Blood pressure
chest. There can indicate
may also be loss of
gastritis and circulating
some times blood volume.
bleeding. • Note changes in • Changes may
mentation and indicate
level of cerebral
consciousness. perfusion
secondary to
hypovolemia,
hypoxemia.
• Avoid rectal • Rectal and
temperature, be esophageal
gentle with GI vessels are
tube insertions. most vulnerable
to rupture.
• Encourage use of • In the presence
soft toothbrush, of clotting factor
avoiding straining disturbances,
for stool, and minimal trauma
forceful nose can cause
blowing. mucosal
bleeding.
• Use small • Minimizes
needles for damage to
injections. Apply tissues,
pressure to reducing risk for
venipuncture bleeding and
sites for longer hematoma.
than usual.

• Recommend • Prolongs
avoidance of coagulation,
aspirin containing potentiating risk
products. of hemorrhage.

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