NURSING CARE PLAN-1Patient Name: - Rab Dino S/O Mola Bux Age: 50Y Sex: Male Ward No: 12 Bed No: 12 Marital Status: Married Medical Diagnoses: Dengue Fever Address : SAKRAND OCCUPATION: Farmer Date: 19--03-2007 ASSESSMENT

NURSING DIAGNOSIS

PLANNING INTERVENTION SCIENTIFIC RATIONALE EVALUATION

SUBJECTIVE:My son’s nose is bleeding asverbalized by the mother.

OBJECTIVE: Weakness

and irritability.

Restlessness.V/S taken asfollows:T: 38P: 55R: 18

Injury, risk forhemorrhagerelated toaltered clottingfactor.

After 1 hr. Ofnursinginterventions,the client willbe able todemonstratebehaviorsthat reducethe risk forbleeding.

1. Assess for signs and symptoms of G.I bleeding. Check for secretions. Observe color and consistency of stools or vomitus.

2. Observe for presence of petechiae, ecchymosis, bleeding from one more sites.

3. Monitor pulse, Blood pressure.

4. Note changes in mentation and level of consciousness.

5. Avoid rectal temperature, be gentle with GI tube insertions.

6. Encourage use of soft toothbrush, avoiding straining for stool, and forceful nose blowing.

7. Use small needles for injections. Apply pressure to venipuncture sites for longer than usual.

8. Recommend avoidance of aspirin containing products.

1. The G.I tract (esophagus and rectum) is the most usual source of bleeding of its mucosal fragility.

2. Sub-acute disseminated intravascular coagulation (DIC) may develop secondary to altered clotting factors.

3. An increase in pulse with decreased Blood pressure can indicate loss of circulating blood volume.

4. Changes may indicate cerebral perfusion secondary to hypovolemia, hypoxemia.

5. Rectal and esophageal vessels are most vulnerable to rupture.

6. In the presence of clotting factor disturbances, minimal trauma can cause mucosal bleeding.

7. Minimizes damage to tissues, reducing risk for bleeding and hematoma.

8. Prolongs coagulation, potentiating risk of hemorrhage.

After 1 hr. Ofnursinginterventions,the clientwas able todemonstratebehaviorsthat reducethe risk forbleeding.

Reference:

Carpenito. L .J. (1995). Nursing Diagnosis (6th Ed.), New Jersey J.B.Lippincott Company. Student name: Akbar Ali Arain Discipline B.Sc. N-1(2007-9)