NURSING CARE PLAN-1

Patient 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

ASSESSMEN NURSING PLANNING INTERVENTION SCIENTIFIC RATIONALE EVALUATION

T DIAGNOSI
S
• Injury, • After 1 hr. Of 1. Assess for signs and 1. The G.I tract (esophagus • After 1 hr. Of
SUBJECTIVE: risk for nursing symptoms of G.I and rectum) is the most nursing
My son’s nose hemorrhag interventions, bleeding. Check for usual source of bleeding interventions,
is bleeding as e the client will secretions. Observe of its mucosal fragility. the client
verbalized by related to be able to color and consistency of was able to
the mother. altered demonstrate stools or vomitus. demonstrate
clotting behaviors 2. Observe for presence of 2. Sub-acute disseminated behaviors
factor. that reduce petechiae, ecchymosis, intravascular coagulation that reduce
the risk for bleeding from one more (DIC) may develop the risk for
bleeding. sites. secondary to altered bleeding.
clotting factors.
3. Monitor pulse, Blood 3. An increase in pulse with
OBJECTIVE: pressure. decreased Blood
• Weakness pressure can indicate
and loss of circulating blood
irritability. 4. Note changes in volume.
• Restlessnes mentation and level of 4. Changes may indicate
s. consciousness. cerebral perfusion
• V/S taken as secondary to
follows: 5. Avoid rectal hypovolemia,
T: 38 temperature, be gentle hypoxemia.
P: 55 with GI tube insertions. 5. Rectal and esophageal
R: 18 6. Encourage use of soft vessels are most
toothbrush, avoiding vulnerable to rupture.
straining for stool, and 6. In the presence of
forceful nose blowing. clotting factor
7. Use small needles for disturbances, minimal
injections. Apply trauma can cause
pressure to venipuncture mucosal bleeding.
sites for longer than 7. Minimizes damage to
usual. tissues, reducing risk for
8. Recommend avoidance bleeding and hematoma.
of aspirin containing
products. 8. Prolongs coagulation,
potentiating risk of
hemorrhage.
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)