ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATION

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