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    Risk For Hemorrhage

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    Judith Arlie Eduarte Pineda
    1) The nursing care plan addresses a patient at risk for hemorrhage related to altered clotting factors who is presenting with fever, headache, muscle pains, and restlessness. 2) Interventions include gentle care of the GI tract, soft toothbrushing and avoiding straining to reduce risk of bleeding, use of small needles

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    Attribution Non-Commercial (BY-NC)
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    Risk For Hemorrhage

    Uploaded by

    Judith Arlie Eduarte Pineda
    533 views3 pages
    1) The nursing care plan addresses a patient at risk for hemorrhage related to altered clotting factors who is presenting with fever, headache, muscle pains, and restlessness. 2) Interventions include gentle care of the GI tract, soft toothbrushing and avoiding straining to reduce risk of bleeding, use of small needles

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    Risk for Hemorrhage

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    1) The nursing care plan addresses a patient at risk for hemorrhage related to altered clotting factors who is presenting with fever, headache, muscle pains, and restlessness. 2) Interventions include gentle care of the GI tract, soft toothbrushing and avoiding straining to reduce risk of bleeding, use of small needles

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    533 views3 pages

    Risk For Hemorrhage

    Uploaded by

    Judith Arlie Eduarte Pineda
    1) The nursing care plan addresses a patient at risk for hemorrhage related to altered clotting factors who is presenting with fever, headache, muscle pains, and restlessness. 2) Interventions include gentle care of the GI tract, soft toothbrushing and avoiding straining to reduce risk of bleeding, use of small needles

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
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    The passage discusses nursing care plans for patients with bleeding risks and gastrointestinal issues. It outlines assessment, diagnosis, planning, interventions, and evaluation.

    The nursing interventions mentioned to reduce the risk of bleeding include being gentle with tube insertions, using a soft toothbrush, avoiding forceful nose blowing and straining, using small needles, and applying pressure to injection sites.

    The signs and symptoms of gastrointestinal bleeding mentioned include checking secretions and observing the color and consistency of stools or vomitus, and looking for the presence of petechiae or ecchymosis.

    NURSING CARE PLAN

    ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION


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

    • Recommend • Prolongs
    avoidance of coagulation,
    aspirin containing potentiating risk
    products. of hemorrhage.

    Collaborative:
    • Monitor Hb and • Indicators of
    Hct and clotting anemia, active
    factors. bleeding, or
    impending
    complications.

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