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    NCP

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    Bella Salik
    1. The patient has a diagnosis of an infectious disease manifested by sudden fever, severe headache, muscle and joint pains, and rashes appearing first on the lower limbs and chest, which may also cause gastritis and bleeding. 2. The nursing diagnosis is risk for injury: hemorrhage related to altered clotting factors. The objective is to keep the patient free from injury as evidenced by vital signs in the normal range and absence of hemorrhage. 3. Interventions include assessing for signs of GI bleeding, monitoring secretions, observing stool/vomit color and consistency, and monitoring pulse and blood pressure. The evaluation is that the goal was met with no evidence of hemorrhage and

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    NCP

    Uploaded by

    Bella Salik
    959 views2 pages
    1. The patient has a diagnosis of an infectious disease manifested by sudden fever, severe headache, muscle and joint pains, and rashes appearing first on the lower limbs and chest, which may also cause gastritis and bleeding. 2. The nursing diagnosis is risk for injury: hemorrhage related to altered clotting factors. The objective is to keep the patient free from injury as evidenced by vital signs in the normal range and absence of hemorrhage. 3. Interventions include assessing for signs of GI bleeding, monitoring secretions, observing stool/vomit color and consistency, and monitoring pulse and blood pressure. The evaluation is that the goal was met with no evidence of hemorrhage and

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    1. The patient has a diagnosis of an infectious disease manifested by sudden fever, severe headache, muscle and joint pains, and rashes appearing first on the lower limbs and chest, which may also cause gastritis and bleeding. 2. The nursing diagnosis is risk for injury: hemorrhage related to altered clotting factors. The objective is to keep the patient free from injury as evidenced by vital signs in the normal range and absence of hemorrhage. 3. Interventions include assessing for signs of GI bleeding, monitoring secretions, observing stool/vomit color and consistency, and monitoring pulse and blood pressure. The evaluation is that the goal was met with no evidence of hemorrhage and

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    959 views2 pages

    NCP

    Uploaded by

    Bella Salik
    1. The patient has a diagnosis of an infectious disease manifested by sudden fever, severe headache, muscle and joint pains, and rashes appearing first on the lower limbs and chest, which may also cause gastritis and bleeding. 2. The nursing diagnosis is risk for injury: hemorrhage related to altered clotting factors. The objective is to keep the patient free from injury as evidenced by vital signs in the normal range and absence of hemorrhage. 3. Interventions include assessing for signs of GI bleeding, monitoring secretions, observing stool/vomit color and consistency, and monitoring pulse and blood pressure. The evaluation is that the goal was met with no evidence of hemorrhage and

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    Name: Ward: San Lorenzo Ward AP:

    Age: Room #: Diagnosis:


    Sex: Hospital:

    Date/ CUES NE NURSING DIAGNOSIS OBJECTIVE OF NURSING EVALUATION


    Time ED CARE INTERVENTIONS
    O: Risk for injury: Hemorrhage Within my 4 hours Assess for signs
    -Weakness related to altered clotting factor. span of care, patient and symptoms of
    and will free from injury as G.I bleeding.
    Irritability. R: This infectious evidence by; Check for
    − Restlessnes disease is manifested by a secretions.
    s. Observe color “Goal Met”
    sudden onset of fever,with a. Maintain vital
    severe headache, muscle and signs within the and consistency After my 8 hours span of care,
    - IVF: joint pains (myalgias and normal range of stools or
    D5LR 80cc/hr arthralgias— BP: 90/70mmHg – vomitus. patient was free from injury as
    followed by severe pain gives it the name 130/90mmHg R: The G.I tract
    evidenced by:
    D5NSS (esophagus and
    breakbone fever or bonecrusher Temp: 36.5-37.5
    disease) and rashes and CR: 60-100bpm rectum) is the a. vital signs within normal
    VS: most usual
    usually appears first on the PR: 60-100bpm range:
    source of
    lower limbs and the chest. There RR: 16-20cpm bleeding of its
    may also be gastritis and some mucosal
    times bleeding. b. Absence of Fragility. BP :120/90 mmHg
    haemorrhage in 2. Observe for Temp : 36 C
    the diferetn presence of RR : 18 cpm
    sites such as petechiae, PR : 75 bpm
    bleeding in the ecchymosis, CR : 78 bpm
    nose, gums, bleeding from one
    ears, hematuria more sites.
    or hematemesis. b. no any evident of hemmorhage
    R: Sub-acute
    disseminated noted.
    intravascular
    coagulation
    (DIC) may
    develop
    secondary to
    altered clotting
    factors.
    3. Monitor pulse,
    Blood pressure.
    R: An increase in
    pulse with

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