HOLY‌‌‌NAME‌‌‌UNIVERSITY‌‌‌ 

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COLLEGE‌‌‌OF‌‌‌HEALTH‌‌‌SCIENCES‌‌‌ ‌
NURSING‌‌‌DEPARTMENT‌‌‌ ‌
City‌‌‌of‌‌‌Tagbilaran‌‌‌ ‌
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NURSING‌‌‌CARE‌‌‌PLAN‌‌ ‌

Daine Petra
Name of Patient: _______________________________________________________________________Age: 3 yrs old
______________________________ Single
Status: ______________________________________
Dauis Bohol
Address: _____________________________________________________ April 10, 2021
Date of Admission: ________________________________ Pediatric
Ward: ________________________ 1
Bed No. __________________
Dengue Fever
Impression: __________________________________________________________________________________________________________________________________________________________

ASSESSMENT PLANNING INTERVENTIONS

PROBLEM CUES/ RATIONALE OF THE DESIRED BEHAVIORAL NURSING
RATIONALE EVALUATION
NURSING DIAGNOSIS PROBLEM OUTCOME(S) OUTCOME(S) INTERVENTIONS
- - Dengue Fever is a After 4 days of - Within the 8hrs shift of 1. - Determine the 1. - Early identification - Goal MET if;
virus-based disease nursing intervention: nursing intervention, patient’s health of possible risks for
Risk for bleeding related spread by mosquitoes. patient’s risk for history for signs that bleeding provides a
to thrombocytopenia as Dengue fever is caused bleeding is reduced as can be associated foundation for 1. Patient’s risk for
evidenced by low by one of four different 1. Patient takes
evidenced by vital signs with a risk for implementing bleeding is
platelet level result on but related viruses. It is measures to
within normal range, bleeding such as liver appropriate reduced as
her CBC, 50,000 mcL. spread by the bite of prevent bleeding
absence of narrowed disease, inflammatory preventive evidenced by
mosquitoes, most and recognizes
commonly the
pulse pressure and bowel disease, or measures. vital signs within
signs of bleeding
mosquito Aedes diminished signs of peptic ulcer disease. normal range,
Subjective: that need to be
aegypti, which is found bleeding 2. Monitor patient’s absence of
reported
in tropic and subtropics (bruises/petechiae, vital signs, especially 2. Hypotension and narrowed pulse
immediately to a
regions. epistaxis, bleeding BP and HR. Look for tachycardia are initial pressure and
Patient verbalized health care
gums, abdominal pains, signs of orthostatic compensatory diminished signs
professional.
 on having a mild hematuria, melena) hypotension. mechanisms usually of bleeding
dcasquejo@hnu.edu.ph
 ASSESSMENT PLANNING INTERVENTIONS
PROBLEM CUES/ RATIONALE OF THE DESIRED BEHAVIORAL
NURSING INTERVENTIONS RATIONALE EVALUATION
NURSING DIAGNOSIS PROBLEM OUTCOME(S) OUTCOME(S)

headache with a Platelets play an noted with bleeding. (bruises/petechia

pain scale of 6 out important role in 2. Patient does not Orthostasis (a drip of e, epistaxis,
of 10 clotting and experience 20 mm Hg in systolic bleeding gums,
 Pain behind her bleeding. In people bleeding as BP or 10 mm Hg in abdominal pains,
with low platelet
eyes, pain scale of 7 evidenced by diastolic BP when hematuria,
count, bleeding is
out of 10 normal blood changing from melena)
more likely to occur,
 That she felt weak, even after slight
pressure, stable supine to sitting
nausea and tired injury and may result hematocrit and position) indicates
to spontaneous hemoglobin reduced circulating April, 14, 2021
bleeding. levels and fluids.
Vital sign as follows;
Objective: desired ranges
Risk for bleeding for coagulation 3. Drugs that interfere T-37.2C
happens with profiles. with clotting
P-120 bpm
 Vomiting disorders that mechanisms or
reduce the quality or 3. Evaluate the patient’s
 T- 38.2C use of any
platelet activity R-25 breaths/p
quantity of increased risk for
 P-120bpm medications that can BP- 80/50 mmHg
circulating platelets bleeding. Salicylates
 R- 22 breaths/m (thrombocytopenia). affect hemostasis
 BP- 90/55mmHg and other NSAIDs CBC- 180, 000 mcL
A reduction in (e.g, anticoagulants,
inhibit
 CBC- 50000 mcL- production of salicylates, NSAIDs, or
cyclooxygenase 1
platelet count platelets from the cancer
(COX)-1, an enzyme
 Weight: 14kg bone marrow is chemotherapy).
linked to cancers of that promotes
the blood and blood- platelet aggregation.
forming organs. Warfarin, an oral
anticoagulant,
inhibits the synthesis
of vitamin K in the
dcasquejo@hnu.edu.ph
 ASSESSMENT PLANNING INTERVENTIONS
PROBLEM CUES/ RATIONALE OF THE DESIRED BEHAVIORAL
NURSING INTERVENTIONS RATIONALE EVALUATION
NURSING DIAGNOSIS PROBLEM OUTCOME(S) OUTCOME(S)

liver, thus reducing

levels of several
subsequent clotting
factors. Heparin, a
parenteral
anticoagulant,
inhibits the action of
thrombin and
prevents formation
of a fibrin clot. Many
drugs used to treat
cancer suppress
bone marrow
function and
therefore the
production of
platelets.

4. The blood clotting

cascade is an integral
system requiring
intrinsic and extrinsic
factors.
Derangements in any
factors can affect
clotting ability.
These laboratory
dcasquejo@hnu.edu.ph
 ASSESSMENT PLANNING INTERVENTIONS
PROBLEM CUES/ RATIONALE OF THE DESIRED BEHAVIORAL
NURSING INTERVENTIONS RATIONALE EVALUATION
NURSING DIAGNOSIS PROBLEM OUTCOME(S) OUTCOME(S)

tests provide
important
information about
the patient’s
coagulation status
and bleeding
4. Review laboratory potential. The
results for specific laboratory
coagulation status as values to be
appropriate: platelet monitored will
count, prothrombin depend on the
time/international patient’s specific
normalized ratio clinical condition. For
(PT/INR), activated patient’s receiving
partial anticoagulants,
thromboplastin time increased levels of
(aPTT), fibrinogen, PT/INR and aPTT
bleeding time, fibrin above therapeutic
degradation values are associated
products, vitamin K, with increased risk
activated coagulation for bleeding.
time (ACT). Reduced platelet
counts may develop
in patients receiving
heparin therapy.

5. These tests are used

dcasquejo@hnu.edu.ph
 ASSESSMENT PLANNING INTERVENTIONS
PROBLEM CUES/ RATIONALE OF THE DESIRED BEHAVIORAL
NURSING INTERVENTIONS RATIONALE EVALUATION
NURSING DIAGNOSIS PROBLEM OUTCOME(S) OUTCOME(S)

to distinguish
bleeding from the
gastrointestinal or
urinary tracts that
may not be visible.

6. Patient with reduced

platelet counts or
impaired clotting
factor activity may
experience bleeding
into tissues that is
out of proportion to
the injury. Prolonged
oozing of blood from
surgical incisions or
areas of skin trauma
is associated with
coagulation
abnormalities.

5. Check stool (guaiac) 7. When bleeding is not

and urine (Hemastix) visible, decreased
for occult blood. Hgb and Hct levels
may be an early
indicator of

dcasquejo@hnu.edu.ph
 ASSESSMENT PLANNING INTERVENTIONS
PROBLEM CUES/ RATIONALE OF THE DESIRED BEHAVIORAL
NURSING INTERVENTIONS RATIONALE EVALUATION
NURSING DIAGNOSIS PROBLEM OUTCOME(S) OUTCOME(S)

bleeding.

6. Assess skin and

mucous membranes
for signs of petechiae,
bruising, hematoma
formation, or oozing
of blood.

7. Monitor hematocrit
(Hct) and hemoglobin
dcasquejo@hnu.edu.ph
 ASSESSMENT PLANNING INTERVENTIONS
PROBLEM CUES/ RATIONALE OF THE DESIRED BEHAVIORAL
NURSING INTERVENTIONS RATIONALE EVALUATION
NURSING DIAGNOSIS PROBLEM OUTCOME(S) OUTCOME(S)

(Hgb).

dcasquejo@hnu.edu.ph