Tuesday, March 9, 2010


Assessment Diagnosis Plan Intervention Rationale Evaluation


“Dumudugo ang ilong ko” as claimed by the patient.


Weakness and irritability.


T: 38.6 C
P: 117 beats/min
R:23 breaths/min
BP:80/50 mmHg
Injury, risk for hemorrhage related to altered clotting factor.

After 1 hr. Of nursing interventions, the client will be able to demonstrate behaviors that reduce the risk for bleeding.

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

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

*Monitor pulse, Blood pressure.

*Note changes in mentation and level of consciousness.

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

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

*Recommend avoidance of aspirin containing products.

*Monitor Hb and Hct and clotting factors.

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

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

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

*Changes may indicate cerebral perfusion secondary to hypovolemia, hypoxemia.
Rectal and esophageal vessels are most vulnerable to rupture.

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

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

*Prolongs coagulation, potentiating risk of hemorrhage.

*Indicators of anemia, active bleeding, or impending complications.

After 1 hr. Of nursing interventions, the client was able to demonstrate behaviors that reduce the risk for bleeding.

Assessment Diagnosis Plan Interventions Rationale Evaluation

“Nilalagnat ako,”as claimed by the patient.


T:38.6 C
P: 117 breaths/min
R:23 breaths/min
BP: 80/50 mmHg

Hyperthermia related to direct effect of circulating endotoxins on the hypothalamus altering temperature regulation

To decrease the body temperature and return to normal

*Provide cool/Tepid sponge bath or immersion

*Wrap extremities with cotton blankets

*Maintain bed rest

*Administer antipyretics as ordered

* May help reduce fever be means of heat loss through evaporation and conduction

To minimize shivering

*To reduce metabolic demands and oxygen consumption
* Used to reduce fever by it’s central action on the hypothalamus

After few hours of interventions, the patient body temperature returned to normal range

Assessment Diagnosis Plan Interventions Rationale Evaluation

“Nahihirapan akong lumunok ng pagkain,” as verbalized by the patient.

(+) lack of chewing
(+) coughing during a swallow
Impaired swallowing related to decreased strength or excursion of muscle involved in mastication as manifested by lack of chewing and coughing during a swallow
Client will pass food and fluid from mouth to stomach safely.

*Auscultate breath sounds

*Move client to chair for meals, snacks and drinks when possible. If the client is in bed elevate the head of the bed.

*Place food midway in oral cavity, provide medium size bite

*Use a glass with nose cut out when drinking

*Massage the laryngopharyngeal musculature gently
*Provide a consistency of food/fluid that is most easily swallowed.
*Evaluates presence of aspiration

*Reduce risk of regurgitation/aspiration

* To adequately trigger the swallowing reflex

*To avoid posterior head tilting

* To stimulate swallowing

* To decrease pain during swallowing.
After the interventions made, the client was able to swallow food/fluids without difficulty

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