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Obejective: Risk for hemorrhage -After 3 hours of Assess the signs and -The GI tract is the After 3 hours of
-Weakness and nursing interventions, symptoms of GI mostusual source of nursing
related to altered
irritability the client will be able bleeding. Check for bleedingof its mucosal interventions, the
clotting factor
-Restlessness to demonstrate secretions. Observe color fragility client is able to
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-V/S taken as behaviors that reduce and consistency of stools -Sub-acute disseminated demonstrate
follows: the risk of bleeding intravascular
or vomitus. behaviors that
T- 38.1 C c coagulation
-Observe for presence reduce the risk of
P- 102 bpm may develop secondary
R- 22 cpm of bleeding
to altered clotting factor. c
BP- 90/60 petichiae, ecchymosis, -an increase in pulse
c bleeding from one more with
sites decrease BP can
-Monitor pulse, BP indicate
loss of circulating blood
-Note changes in level
volume.
of
-Changes may indicate
consciousness.
cerebral perfusion
-Encourage use of soft problems.
toothbrush. Avoid -Minimal trauma can
straining in stool, and cause mucosal bleeding
forceful nose blowing.- -Minimize damage to
Use small needles tissues, reduce risk for
forinjections. Apply bleeding and hematoma
c
pressure to venipuncture
sites for longer than
usual
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