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Cues

S> O> patient manifested the following which put his at risk for injury Low platelet count Abnormal blood profile Tissue Hypoxia Patient may manifest Sensory dysfunction Broken Skin VS: BP- 100/60 PR- 63 RR- 20 TEMP-36.3

Nursing Diagnosis
Risk for injury r/t abnormal blood profile as evidenced by decrease platelet count.

Analysis
Risk of Injury as a result of environmental conditions interacting with the individuals adaptive and defensive resources. It is also because of the infection of DHF I Virus that destroys the platelets which place the patient at risk of bleeding. When the blood vessels are cut or damage, the loss of blood from the system must be stop before shock and possible death may occur. This is accompanied by solidification of

Planning
Short term: After 8 hour of nursing Interventions, patient will demonstrate techniques behavior, lifestyle changes to risk factors and protect self.

Intervention
>Establish rapport

Rationale
>to gain patients trust

Evaluation
Short term: After 8 hours of nursing Interventions, patient would have demonstrated techniques behavior, lifestyle changes to risk factors and protect self.

>Assess level of consciousness and cognitive level

>assist in determining pt. s ability to protect self and comply with required selfprotective actions > Minimizes injury to occur

Long Term: After 1 day of nursing intervention, the patient will be free from injury.

>Provide safe environment (pad, side rails, prevent falls) > Observe for each stool color, consistency and amount >Observe for hemorrhagic manifestation, ecchymosis, epistaxis, Petechiae, and

> Permits detection of bleeding in GI tract > Indicate altered clotting mechanism

Long Term: After 1 day of nursing intervention, the patient would have been free from injury.

the blood, a process called coagulation or clotting. If the value should stop below normal,(150,000 -450,000 g/dl), there is a danger of uncontrolled bleeding because of the essential role that platelets have in blood clotting.

bleeding gums >Encourage intake of foods with high content of Vit. C > Promotes healing and boost the resistance of the body against infection

> Assess patients condition and monitor vital signs. > Provide comfort measures, such as stretching bed linens.

> To obtain baseline data

> To promote relaxation and alleviate.

> Avoid SC, IM route of injection as possible

> Minimizes tendency of trauma or bleeding