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TUBASCO, Ace Joshua D.

NURSING
ASSESSMENT DIAGNOSIS PLANNING RATIONALE
INTERVENTION

Subjective: Risk for Bleeding Goal: 1. Determine the patients health Early identification of possible
Mga ilang araw Secondary to history for signs that can be risks for bleeding provides a
din na may dugo ang Acute After 4 hours of nursing associated with a risk for bleeding foundation for implementing
tae ko as verbalized Gastroenteritis intervention, the patient such as liver disease, inflammatory appropriate preventive
by the aptient will be able to : bowel disease, or peptic ulcer measures.
disease.
Objectives: takes measures to
prevent bleeding 2. Monitor patients vital signs, Hypotension and tachycardia
- Patient was and recognizes signs especially BP and HR. Look for are initial compensatory
diagnosed with of bleeding that signs of orthostatic hypotension. mechanisms usually noted with
Acute need to be reported bleeding. Orthostasis (a drip of
Gastroenterities, immediately to a 20 mm Hg in systolic BP or 10
to consider health care mm Hg in diastolic BP when
Diverticuliis, professional. changing from supine to sitting
Type 2, not experience position) indicates reduced
Uncontrolled bleeding as 3. Evaluate the patients use of any circulating fluids.
Diabetes evidenced by medications that can affect Drugs that interfere with
Mellitus normal blood hemostasis (e.g, anticoagulants, clotting mechanisms or platelet
- Patient is taking pressure, stable salicylates, NSAIDs, or cancer activity increased risk for
Antihemophilic hematocrit and chemotherapy). bleeding. Salicylates and other
Agent hemoglobin levels NSAIDs inhibit
(TrenaXemic and desired ranges cyclooxygenase 1 (COX)-1, an
Acid) for coagulation enzyme that promotes platelet
- Brownish-colored profiles. aggregation. Warfarin, an oral
Stool anticoagulant, inhibits the
synthesis of vitamin K in the
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
4. Review laboratory results for platelets.
coagulation status as appropriate: Review laboratory results for
platelet count, prothrombin coagulation status as
time/international normalized ratio appropriate: platelet count,
(PT/INR), activated partial prothrombin time/international
thromboplastin time (aPTT), normalized ratio (PT/INR),
fibrinogen, bleeding time, fibrin activated partial thromboplastin
degradation products, vitamin K, time (aPTT), fibrinogen,
activated coagulation time (ACT). bleeding time, fibrin
degradation products, vitamin
5. Check stool (guaiac) and urine K, activated coagulation time
(Hemastix) for occult blood. (ACT).

6. Monitor hematocrit (Hct) and These tests are used to


hemoglobin (Hgb). distinguish bleeding from the
gastrointestinal or urinary tracts
that may not be visible.
When bleeding is not visible,
decreased Hgb and Hct levels
may be an early indicator of
bleeding.
Sumbitted by:
Ace Joshua D. Tubasco BSN IV-A
Sumbitted to:
Ms. Linda Sobrevega, RN MAN

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