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NCP

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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1K views2 pages

NCP

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

Uploaded by

Bella Salik
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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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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