Assessment

Subjective:
nanghihina ako lalo
na pag naglalakad
inaalalayan ako. As
verbalized by the
patient

Objective:
> Decreased strength
in lower extremities
> Weak in
appearance
> Limited motion
> Headache
> Dizziness

Planning
After 8 hours of nursing
intervention, the patient will be
able to display homeostasis as
evidenced by absence of
bleeding and will be able to
demonstrate techniques in
ambulating with assistance.

RiskIntervention
for Injury

Scientific Rationale

Avoid injections, rectal temperatures and rectal tubes. Protects patient from procedure-related causes of
Administer rectal suppositories with caution.

Maintain a safe environment. Keep all necessary

objects and call bell within patients reach and
place bed in low position.

Maintain bed rest or chair rest when platelets are

below 10,000 or as individually appropriate. Assess
medication regimen.

Hematest body fluids: urine, stool, vomitus, for occult

blood.

Observe for or report epistaxis, hemoptysis,

hematuria, non menstrual vaginal bleeding, or
oozing from lesions or body orifices and/or IV
insertion sites.

Monitor for changes in vital signs and skin color: BP,

pulse, respirations, skin pallor and discoloration.

Review laboratory studies: PT, aPTT, clotting time,

platelets, Hb/Hct.

Administer blood products as indicated.

Avoid use of aspirin products and NSAIDs, especially
in presence of gastric lesions.

bleeding: insertion of thermometers, rectal tubes can

damage or tear rectal mucosa. Some medications
need to be given via suppository, so caution is
advised.

Reduces accidental injury, which could result in

bleeding.

Reduces possibility of injury, although activity needs to

be maintained. May need to discontinue or reduce
dosage of a drug. Patient can have a surprisingly
low platelet count without bleeding.

Prompt detection of bleeding or initiation of therapy

may prevent critical hemorrhage.

Spontaneous bleeding may indicate development of

DIC or immune thrombocytopenia, necessitating
further evaluation and prompt intervention.

Presence of bleeding and hemorrhage may lead to

circulatory failure and shock.

Detects alterations in clotting capability; identifies

therapy needs. Many individuals (up to 80%) display
platelet count below 50,000 and may be
asymptomatic, necessitating regular monitoring.

Transfusions may be required in the event of persistent

or massive spontaneous bleeding.

These medications reduce platelet aggregation,

impairing and prolonging the coagulation process,
and may cause further gastric irritation, increasing
risk of bleeding.

Evaluation
After 8 hours of
nursing
intervention, the
patient was able to
display
homeostasis as
evidenced by
bleeding and able
to demonstrate
ambulating
techniques with
assistance.