NURSING CARE PLAN
ASSESSMENT
Subjective: “Dumudugo ang ilong ng anak ko” (My son’s nose is bleeding) as verbalized by the mother. Objective: •
DIAGNOSIS
Injury, risk for hemorrhage related to altered clotting factor.
INFERENCE •
This infectious disease is manifested by a sudden onset of fever, with severe headache, muscle and joint pains (myalgias and arthralgias— severe pain gives it the name breakbone fever or bonecrusher disease) and rashes and usually appears first on the lower limbs and the chest. There may also be gastritis and some times bleeding.
PLANNING •
After 1 hr. Of nursing interventions, the client will be able to demonstrate behaviors that reduce the risk for bleeding.
INTERVENTION
Independent: • Assess for signs and symptoms of G.I bleeding. Check for secretions. Observe color and consistency of stools or vomitus. • Observe for presence of petechiae, ecchymosis, bleeding from one more sites. •
RATIONALE
The G.I tract (esophagus and rectum) is the most usual source of bleeding of its mucosal fragility. Sub-acute disseminated intravascular coagulation (DIC) may develop secondary to altered clotting factors. An increase in pulse with decreased Blood pressure can indicate loss of circulating blood volume. Changes may indicate cerebral perfusion secondary to hypovolemia, hypoxemia.
EVALUATION •
After 1 hr. Of nursing interventions, the client was able to demonstrate behaviors that reduce the risk for bleeding.
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Weakness and irritability. Restlessness. V/S taken as follows: T: 38 P: 55 R: 18
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Monitor pulse, Blood pressure.
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Note changes in mentation and level of consciousness.
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Avoid rectal temperature, be gentle with GI tube insertions. Encourage use of soft toothbrush, avoiding straining for stool, and forceful nose blowing. Use small needles for injections. Apply pressure to venipuncture sites for longer than usual. Recommend avoidance of aspirin containing products.
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Rectal and esophageal vessels are most vulnerable to rupture. In the presence of clotting factor disturbances, minimal trauma can cause mucosal bleeding. Minimizes damage to tissues, reducing risk for bleeding and hematoma. Prolongs coagulation, potentiating risk of hemorrhage. Indicators of anemia, active bleeding, or impending complications.
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Collaborative: • Monitor Hb and Hct and clotting factors.
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