ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATION

Subjective: • Injury, risk for • This infectious • After 1 hr. Of • Assess for • The G.I tract • After 1 hr. Of
hemorrhage disease is nursing signs (esophagus and nursing
“May
related to manifested by interventions, and symptoms rectum) is the interventions,
nagruruluwas na
pantal na mapula altered clotting a sudden the client will of most usual the client
sa takyag kan aki factor. onset of fever, be able to G.I bleeding. source of was able to
ko” as verbalized with severe demonstrate Check for bleeding of its demonstrate
by the mother. headache, behaviors secretions. mucosal behaviors
muscle and that reduce Observe color fragility. that reduce
Objective: joint pains the risk for and consistency • Sub-acute the risk for
• Weakness and (myalgias and bleeding. of stools or disseminated bleeding.
irritability. arthralgias— vomitus. intravascular
severe pain • Observe for coagulation
• Restlessness. gives it the presence of (DIC) may
• V/S taken as name petechiae, develop
follows: breakbone ecchymosis, secondary to
T: 37.5
fever or bleeding from altered clotting
P: 55
R: 18 bonecrusher one factors.
disease) and more sites. • An increase in
rashes and • Monitor pulse, pulse with
usually Blood pressure. decreased
appears first • Note changes Blood pressure
on the lower in can indicate
limbs and the mentation and loss of
chest. There level of circulating
may also be consciousness. blood volume.
gastritis and • Changes may
some times indicate
bleeding. cerebral
perfusion
secondary to
hypovolemia,
hypoxemia.