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Assessment Diagnosis Planning Intervention Rationale Evaluation

The document discusses a patient assessment and nursing care plan for a patient presenting with petechial rashes and hematoma who is at risk for bleeding due to low platelet count. The plan includes monitoring vital signs and signs of bleeding, maintaining safety precautions, transfusing blood products as needed to address anemia, and communicating with the transfusion center about potential need for platelet transfusion. After 6 hours of nursing interventions, the patient's risk for bleeding was reduced as evidenced by normal vital signs and absence of bleeding signs.

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Adrian Mallar
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32 views3 pages

Assessment Diagnosis Planning Intervention Rationale Evaluation

The document discusses a patient assessment and nursing care plan for a patient presenting with petechial rashes and hematoma who is at risk for bleeding due to low platelet count. The plan includes monitoring vital signs and signs of bleeding, maintaining safety precautions, transfusing blood products as needed to address anemia, and communicating with the transfusion center about potential need for platelet transfusion. After 6 hours of nursing interventions, the patient's risk for bleeding was reduced as evidenced by normal vital signs and absence of bleeding signs.

Uploaded by

Adrian Mallar
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION Assess and Monitor vital signs

RATIONALE Increase heart rate and orthostatic changes company bleeding Bleeding may be obvious ( petechiae, epistaxiss, bleeding gums, hematoma, melena ) Spontaneous bleeding can occur at platelet count <50,000 /mm3 As reminder of bleeding precautions and to apply pressure to venipunctures. To prevent falls and injury

EVALUATION

Subjective: ang dami kong pasa at rashes as verbalized by the patient.

Risk for bleeding related to decreased platelets count

Objective: o o o Petechial Rashes Hematoma Hematology Platelet: 120 Hgb: 172 Hct: 0.50 Vital signs as follows Temp.: 38.3c HR: 137bpm RR: 40bpm BP: 130/100

After 6 hours of nursing intervention, patients risk for bleeding is reduced as evidenced by vital signs within normal range, absence of narrowed pulse pressure and diminished signs of bleeding ( petechiae, epistaxiss, bleeding gums, hematoma, melena )

Assess for any sign of bleeding

Monitored platelet count

Goal partially met. After 6 hours of nursing intervention, patients risk for bleeding is reduced as evidenced by vital signs within normal range, absence of narrowed pulse pressure and diminished signs of bleeding ( petechiae, epistaxiss, bleeding gums, hematoma, melena )

Placed sign over patients bed

Maintained safe environment for patient Transfused PRBC as prescribed.

To restore Hgb/Hct level and to replaced blood loss

Communicated anticipated need for platelet support to transfusion center

To assure availability and readiness of plateless when needed

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