Nursing Diagnosis Analysis Goals and Objectives Intervention Rationale Evaluation

After 1 hr. Of
Injury, risk for Scientific Analysis: Goals: nursing
hemorrhage This infectious After 1 hour Of interventions,
related to disease is nursing the client
altered clotting manifested by interventions, was able to
factor. a sudden the client will demonstrate
onset of fever, be able to behaviors
with severe demonstrate that reduce
Subjective: headache, behaviors the risk for
“Nanghihina ang anak muscle and that reduce bleeding.
ko, pero wala naming joint pains the risk for
siyang lagnat” (myalgias and bleeding.
verbalized by the arthralgias—
mother. severe pain Objectives:
gives it the
Objective: name breakbone After 10 minutes of Check for The G.I tract
Weakness and fever or nursing intervention secretions. (esophagus and
irritability. bonecrusher the patient will be Observe color rectum) is the
Restlessness. disease) and able to assess for and consistency most usual
rashes and signs and symptoms of stools or source of
V/S taken as
usually of G.I bleeding vomitus. bleeding of its
follows:
T: 36.5 appears first mucosal
P: 55 on the lower After 10 minutes of fragility.
R: 18 limbs and the nursing intervention Observe for Sub-acute
chest. There the patient will be presence of disseminated
may also be able to assess for petechiae, intravascular
gastritis and infection progress ecchymosis, coagulation
some times bleeding from one (DIC) may
bleeding. more sites. develop
secondary to
Situational Analysis: altered clotting
The patient has no After 10 minutes of factors.
signs of bleeding, but nursing intervention Monitor pulse, An increase in
is manifesting the the patient will be Blood pressure. pulse with
early signs of dengue able to obtain baseline Note changes in decreased
such as body data. mentation and Blood pressure
weakness, if the level of can indicate
infection will not be consciousness. loss of
prevented, the circulating
potential problem of blood volume.
bleeding will arise Changes may
and will further indicate
increase the chance cerebral
perfusion
of complication
secondary to
hypovolemia,
hypoxemia.

After 20 minutes of
nursing intervention Avoid rectal Rectal and
the patient will be temperature, provide esophageal
able to decrease TSB if fever is vessels are
discomfort and pain present, provide most vulnerable
stimuli and promote therapeutic touch to rupture.
comfort. In the presence
of clotting factor
disturbances,
minimal trauma
can cause
mucosal
bleeding.
Encourage use of Minimizes
soft toothbrush, damage to
avoiding straining tissues,
for stool, and reducing risk for
forceful nose bleeding and
blowing. hematoma.
Use small Prolongs
needles for coagulation,
injections. Apply potentiating risk
pressure to of hemorrhage.
 venipuncture
sites for longer
than usual.

After 10 minutes of
nursing intervention Provide health Providing health
the patient will be teaching about aspirin teaching to patient is
able to understand the and aspirin containing one way to speed up
cause of aspirin to products and its its recovery
dengue patient possible effects to
dengue patient

Collaborative:
Monitor Hb and Indicators of
Hct and clotting anemia, active
factors. bleeding, or
impending
complications
Recommend liquid
diet and avoid high in Fatty foods is hard
fats and high in salt to digest for dengue
food, encourage fluid patient who have
intake decreased peristalsis