Assessment Subjective: N/A

Diagnosis Risk for bleeding related to altered clotting factor

Planning Short Term: -After 2-3 hours of nursing interventions, the client will be able to demonstrate behaviors that reduce the risk of bleeding.

Intervention Assess the signs and symptoms of GI bleeding. Check for secretions. Observe color and consistency of stools or vomitus. Monitor pulse, BP

Rationale The GI tract is the most usual source of bleeding of its mucosal fragility

Evaluation Goal met

Objective: -restlessness - decreased platelet count

Long Term: After 8 hours of nursing interventions, the patient will be free from injury to prevent severe bleeding. Encourage use of soft toothbrush. Avoid straining in 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

An increase in pulse with decrease BP can indicate loss of circulating blood volume. Minimal trauma can cause mucosal bleeding

Minimize damage to tissues, reduce risk for bleeding and hematoma.

Prolongs coagulation, potentiating risk of hemorrhage

Assessment

Diagnosis

Planning Short Term:

Intervention

Rationale

Evaluation

Subjective: Matagal na hindi nakakatae yan. Mula nung ma-admit pa yan dito. as verbalized by the mother of the patient.

Risk for constipation related to irregular defecation habits as evidence by decreased frequency of defecation in a week.

After 2-3 hrs of nursing interventions patient will demonstrate behaviors changes to developing problem

Auscultate abdomen for presence, location and characteristics of bowel sounds. Encourage balance fiber and bulk habit. Promote adequate fluid intake, including water and highfiber fruit juice; also suggest drinking warm fluid Ascertain frequency, color, consistence, amount of stool

To improve consistence of the stool and facilitate passage through colon.

Goal met

Long Term:

For impact effect of change in bowel function and bowel sounds aids in reflecting bowel activity

Objective: irregular defecation habits inadequate toileting recent environmental changes

After 8 hours of nursing interventions patient will improve her bowel pattern

Provide as baseline of comparison, promotes recognition of changes

Educate mother of client about safe and risky practice for managing constipation Review appropriate use of medication. Discuss clients current medication regimen with physician

Information can help client to make beneficial choices when needed

To determine if drugs contributing to constipation can be discontinue or change

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: Ang init init ng anak ko. May lagnat na yata to. as verbalized by mother of client Objectives: - T =38c - Flushed skin -Warm to touch

Hyperthermia related to physiological factors secondary to dengue hemorrhagic fever

Short Term: After 2-3 hours of nursing interventions, the clients temperature will be lowered to 37c.

Provide tepid sponge bath

Heat loss by means of evaporation

Goal met

Promote surface cooling by means of undressing Provide cool

Heat loss by means of conduction

Heat loss by means of convection

Long Term: After 8 hours of nursing interventions client will be able to maintain core temperature within normal range.

Environment Maintain bed rest or minimize movement

Reduce metabolic demands of oxygen consumption

Discuss importance of adequate fluid intake.

To prevent Dehydration Pharmacological treatment for fever(rationale)

Give antipyretic as prescribed by the physician.