Nursing Care Plan

presentation

Submitted By:
Abang, Trinemie
Barredo, Pauline Lanticse Bayquin, Jeian Xyrra Gallana
Gimena, Nanako
Loredo, Donnah Jean Panoy
Lozada, Rapunzel Laviña
Silades, Rhea Buton
 Nursing Care Plans for David Garcia:
Risk for Bleeding related to Dengue Fever as
evidence by Low Platelet count of
100,000/mcL

Nursing Diagnosis 1
Assessment Data
Subjective Data:
Age: 3 months old
Pt. David has fever.
Pt. David has been vomiting for 10 hrs.

Objective Data:
Vital Signs:
Temperature: 38.5 degrees Celsius
Heart Rate: 100 bpm
Respiratory Rate: 22 breaths/min
Blood Pressure: 100/60 mmHg
02 sat: 97%
Platelet: 100,000/mcL
RISK FOR BLEEDING RELATED TO DENGUE
FEVER AS EVIDENCE BY LOW PLATELET
COUNT OF 100,000/MCL

Nursing Diagnosis(Problem & Etiology)

Goals & Objectives
Short-term goals Long-term goals
Within 24 hrs. the Within 7 days nursing
patient's mother will: of intervention,
• Educate in preventive patient will:
measures from injuries of • Able to return to normal
the patient. platelet count back to a
Within 3 days of nursing range of 150,000/mcL to
intervention, the patient 400,000/mcl.
will:
• Increase platelet count
higher than 100,000/mcL.
Nursing Interventions & Rationale
Independent Nursing Interventions:
1. Assess vital signs, including blood pressure, pulse,
and respirations.
R: To determine if an intravascular fluid deficit exists.
2. Assess skin color and moisture, urinary output.
R: Changes in these signs may be indicative of blood
loss affecting systemic circulation or local organ
function, such as kidneys.
3. Review laboratory data (e.g., complete blood
count (CBC), and platelet numbers and functions)
R: To evaluate bleeding risk.
4. Monitor closely for overt bleeding and observe
petechiae.
R: To identify excessive bleeding.
Dependent Nursing Intervention:
1. Hematest secretions ad excretions for occult
blood.
R: For early identification of internal bleeding.
2. Protect the patient from trauma such as accidental
lacerations.
R: To prevent from bleeding.
3. Be prepared to administer hemostatic agents, if
needed.
R: To promote clotting and diminish bleeding by
increasing coagulation factors.
4. Be prepared to administer proton pump inhibitors,
if needed.
R: To reduce risk of gastrointestinal bleeding.
Nursing Interventions & Rationale
Collaborative Nursing Interventions:
1.Collaborate in evaluating the need for replacing blood loss or specific
components and be prepared for emergency interventions.
R: Institution or physician may have specific guidelines for transfusion,
such as platelet count less than 20, 000/mcL or Hg less that 7 g/dL, in
addition to the clients's clinical status.

2. Provide information to the family about bleeding complications.

Instruct family regarding: Specific signs of bleeding requiring healthcare
provider notification, such as active bright bleeding anywhere,
prolonged epistaxis or trauma, black tarry stools, and so forth

3. Contact a Pediatrician.
R: For dietary measures to improve blood clotting, such as foods rich in
Vitamin K.
Evaluation:
Short-term Goal Met: Long-term Goal Met:
Within 24 hours of
nursing interventions, patient's mother Within 7 days of nursing intervention,
was: was:
• Able to practice preventive measures • Able to return to normal platelet count
from injuries of the patient. back to a range of 150,000/mcL to
Within 3 days of nursing intervention, the 400,000/mcL.
patient was:
• Able to increase platelet count higher
than 100,000/mcL.
 Nursing Care Plans for David Garcia:
High Risk for Fluid Volume deficit related to
increased fluid loss from vomiting and fever,
as evidenced by sunken eyeballs and the
presence of dengue fever

Nursing Diagnosis(Problem & Etiolog)

Goals & Objectives
Short-term goals Long-term goals
Within ( 48) hours of nursing Within ( 72) hours of nursing
intervention the patient intervention the patient
will: will:
Decrease temperature Prevent risk of dehydration
from 38.5 C to 37.0 • Decrease risks for
Possess sufficient fluid complications of fluid
balance volume deficit
Nursing Interventions & Rationale
Independent Nursing Interventions:
1.Assess patient condition
R: To monitor others signs and symptoms
2. Monitor electrolyte levels
R: Electrolyte level should be monitored regularly to
ensure proper balance
3.assess the patient oral fluid intake
R: To prevent further dehydration
Dependent Nursing Intervention:
1.Administer intravenous fluid as prescribed by the
doctor
R: Intravenous fluid are given to replace lost fluids
and electrolytes
2. Administer antipyretic medication as prescribed to
manage and reduce fever.
R: Antipyretic medication helps in reducing fever and
provides comfort to the child.
Nursing Interventions & Rationale
Collaborative Nursing Interventions:

1. Collaborate with the healthcare team to

conduct regular blood tests to monitor David's
platelet count and overall health.
R: Regular monitoring of platelet count helps in
detecting any significant changes and guides the
need for interventions to prevent complications
such as
Evaluation:
Short-term Goal Met: Long-term Goal Met:

Within (48) hours of nursing interventions Within (72) hours of nursing interventions
the patient was: the patient was:

• Patient David's condition stabilize by • Completely recovered from

managing his fever and vomiting. Dengue fever.
Thank you!