NURSING

PROBLEM with
CUES
NURSING DIAGNOSIS
with RATIONALE (with
reference)
(SMART) GOALS/
OBJECTIVES
NURSING
INTERVENTIONS
RATIONALE OR
INTERVENTIONS
E!PECTED
OUTCOMES
EVALUATION
2.Risk for Bleeding
Date: Nov. 27, 2009
S"#$ecti%e&
Ang dami niyang
pasa at rashes as
verbalized by the
patients mother.
O#$ecti%e&
!ete"hial #ashes
$""hymoses
%ematology:
&!latelet: '' (0
)
*+,
&%gb& -'.7
&%"t& - 0.20
.*/ as 0ollo1s:
&2: )9.) 3
&%#: ()7 bpm
&##: 40 bpm
&5!: (00*90mm%g

%igh #is6 0or 7n89ry:
5leeding related to
de"reased platelet "o9nt
R(ti)n(*e&
!latelets play an
important role in
"lotting and bleeding.
7n people 1ith a lo1
platelet "o9nt, bleeding
is more li6ely to o""9r,
even a0ter a slight
in89ry. ,o1 platelet
"o9nt may res9lt in
spontaneo9s bleeding.
:;er"6 ;an9al, 2009,
/e". ), "hapter 49<
Sh)rt ter+ ,)(*&
=ithin the shi0t,
patients ris6 0or
bleeding is red9"ed as
eviden"ed by vital
signs 1ithin normal
range, absen"e o0
narro1ed p9lse
press9re and
diminished signs o0
bleeding :br9ises*
pete"hiae, epista>is,
bleeding g9ms,
abdominal pain,
hematemesis,
hemat9ria, melena<.
L)n, ter+ ,)(*&
=ithin 2&) days o0
n9rsing interventions,
patient 1ill maintain
red9"ed ris6 o0
bleeding as eviden"e
by normal platelet
"o9nt and absen"e o0
any signs o0 bleeding
:br9ises*pete"hiae<
(. Assessed and
monitored vital signs.
2. Assessed 0or any
signs o0 bleeding.
). ;onitored platelet
"o9nt.
4. Avoided 7. */3
in8e"tions and re"tal
pro"ed9res :s9"h as
enemas and re"tal
temperat9re ta6ing<
as ne"essary.
(. 7n"reased heart rate
and orthostati"
"hanges a""ompany
bleeding. :N3!. )
rd
ed., /"hroeder ?
@ones, (994, p )A9<
2. 5leeding may be
obvio9s :br9ises*
pete"hiae epista>is,
bleeding g9ms,
abdominal pain,
hematemesis, melena,
hemat9ria<. :N3!. )
rd
ed., /"hroeder ?
@ones, (994, p )A9,
422<
). /pontaneo9s bleeding
"an o""9r at platelet
"o9nt BC0,000*mm)
4. 3an stim9late
bleedingD to red9"e
9nne"essary tra9ma.
:N3!. )
rd
ed., ;"
;"3arthy ?
/"hroeder, (994, p
)A), 42)<
(. !atient 1ill
red9"e ris6 o0
bleeding.
2. !atient 1ill be
0ree 0rom any
in89ry.
Sh)rt ter+
,)(*&
Eoal partially
met.
A0ter A ho9rs
shi0t, patient
ris6 0or
bleeding 1as
red9"ed as
eviden"ed by
vital signs
1ithin normal
range, absen"e
o0 narro1ed
p9lse press9re
and diminished
signs o0
bleeding
:epista>is,
hematemesis,
hemat9ria,
melena<
Nov. 29, 2009
V/S as follows:
5!F (00*70 mm%g
2F )'. ( 3
%#F ((9 bpm
##F )0 bpm
C. !la"ed sign over
patients bed.
'. ;aintained sa0e
environment 0or
patient.
7. 2rans09sed !#53 as
pres"ribed.
A. 3omm9ni"ated
anti"ipated need 0or
platelet s9pport to
trans09sion "enter.
C. As reminder o0
bleeding pre"a9tions
and to apply press9re
a0ter venip9n"t9res.
:N3!. )
rd
ed., !9zas,
(994, p 42C<
'. 2o prevent 0alls*
in89ry.:N3!. )
rd
ed.,
/"hroeder, (994, p
422<
7. 2o restore %gb*%"t
level and to repla"e
blood lost. :N3!. )
rd
ed., /"hroeder ?
@ones, (994, p )A9<
A. 2o ass9re availability
and readiness o0
platelets 1hen
needed. :N3!. )
rd
ed.,
/"hroeder, (994, p
40'<
L)n, ter+
,)(*&
Eoal partially
met.
A0ter ) days o0
n9rsing
interventions,
patient
maintained
red9"ed ris6 0or
bleeding as
eviden"ed by
diminished
signs o0
bleeding
:br9ises*pete"hi
ae<.
De". ), 2009
Hematology:
!latelet G (0 >
(0
)
*+,
%gb& -0.2A
%"t& - 0.9'