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Problem # 3: Risk for injury r/t abnormal blood profile as evidenced by decrease platelet count
Assessment Nursing Scientific Objectives Interventions Rationale Expected
Diagnosis explanation Outcome
S>ø Risk for Risk of Injury as Short term: >Establish rapport >to gain Short term:
O> patient injury r/t a result of After 4 hours of patient’s trust After 4 hours of
manifested the abnormal environmental Nursing Nursing
following which put blood profile conditions Interventions, >Assess level of >assist in Interventions,
his at risk for injury as evidenced interacting with pt will consciousness determining pt. pt will have
Low platelet by decrease the individuals demonstrate and cognitive ‘s ability to demonstrate
count platelet adaptive and techniques level protect self techniques
Abnormal count. defensive behavior, and comply behavior,
blood profile resources. It is lifestyle with required lifestyle
Tissue also because of changes to risk self protective changes to risk
Hypoxia the infection of factors and actions factors and
Pt may manifest DHF I Virus that protect self. protect self.
Sensory destroys the
dysfunction platelets which Long Term: Long Term:
Broken Skin place the After 1 days of >Provide safe > Minimizes After 1 days of
Malnutrition patient at risk of NI, the patient’ environment (pad, injury to occur NI, the the
bleeding. When will be free side rails, prevent patient’ will
the blood from injury. falls) have been
vessels are cut free from
or damage , the > Observe for > Permits injury.
loss of blood each stool color, detection of
from the system consistency and bleeding in GI
must be stop amount tract
before shock
and possible >Observe for > Indicate
death may hemorrhagic altered clotting
occur. This is manifestation, mechanism
accompanied ecchymosis,
by solidification epistaxis,
of the blood, a Petechiae, and
process called bleeding gums
coagulation or
clotting. If the
value should
stop below >Encourage > Promotes
normal, intake of foods healing and
(150,000 with high content boost the
-450,000 g/dl), of Vit. C resistance of
there is a the body
danger of against
uncontrolled infection
bleeding
because of the > Assess pt’s > To obtain
essential role condition and baseline data
that platelets monitor vital
have in blood signs.
clotting.
> Provide comfort > To promote
measures, such relaxation and
as stretching bed alleviate .
linens.
>decrease
motility of
gastro
intestinal troat Auscultate Reflecting
physical and
activity characteristics of
bowel sounds
Encourage To improve
balance fiber and consistence of
bulk habit the stool and
facilitate
passage
through colon
Promote To promote
adequate fluid soft stool and
intake, including stimulate
water and high- bowel activity
fiber fruit juice;
also suggest
drinking warm
fluid
Ascertain Provide as
frequency, color, baseline of
consistence, comparison,
amount of stools promotes
recognition of
changes
Review To determine if
appropriate use of drugs
medication. contributing to
Discuss client’s constipation
current can be
medication discontinue or
regimen with change
physician
Problem # 5 Impaired tissue integrity related to mechanical and chemical factor of IV infusion and blood test; secondary to haematoma
as evidence by collection of blood on the upper extremities.
Nursing Scientific Expected
Assessment Diagnosis Explanation Objectives Interventions Rationale Outcome
Provide To ease patient’s
S=Ø Impaired Hematoma is a ST comfortable anxiety and to help ST
O= patient tissue localized After 4 hrs of environment the patient recover
manifested by: integrity collection of nursing faster for proper Patient shall
pallor related to blood, usually interventions hygiene of the have
haematoma mechanical clotted, in a tissue patient will patient demonstrate
on both and chemical or organ. demonstrate behavior to
upper factor of IV Hematomas can behavior to Provide comfort For proper hygiene reduce
extremities infusion and occur almost reduce the measures by AM of the patient hematoma
Assess To comparative
skin/tissues, bony baseline
prominences,
pressure areas and
wounds