slh-cnp-dengue (2).docx_0
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an2netlazarCENTRO ESCOLAR
UNIVERSITYCity of Malolos, Bulacan
NURSING DEPARTMENT
COMPREHENSIVE
NURSING CAREPLANSAN LAZARO HOSPITAL
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currently no availablevaccine, but outbreaks can be prevented by reducing the habitat
and number of mosquitoes, and limiting exposure to bites.
Health officials last year warned of a possible epidemic of dengue fever in Asia. The
World Health Organization said in July that 2007 could be on a par with 1998, when
nearly 1,500 people died in the region from the disease. The Philippines has recorded
nearly 40,000 cases of dengue fever in the first 11 months of the year, the health
department said. The department has said about 290 people had died from dengue
fever in the first 10 months of the year,
Treatment of acute dengue is supportive, using either oral or intravenous rehydration for
mild or moderate disease, and blood transfusions for more severe cases. Rates of
infection have increased dramatically over the last 50 years with around 50100 million
people infected yearly. A global disease, dengue is currently endemic in more than
110 countries with 2.5 billion people living in areas where it is prevalent. Early
descriptions of the condition date from 1779, and its viral cause and the transmission
were elucidated in the early 20th century. Dengue has become a worldwide problem
since the Second World War.
http://en.wikipedia.org/wiki/Vaccinehttp://en.wikipedia.org/wiki/Vaccinehttp://en.wikipedia.org/wiki/Rehydrationhttp://en.wikipedia.org/wiki/Blood_transfusionhttp://en.wikipedia.org/wiki/Endemic_(epidemiology)http://en.wikipedia.org/wiki/World_War_IIhttp://en.wikipedia.org/wiki/Vaccinehttp://en.wikipedia.org/wiki/Rehydrationhttp://en.wikipedia.org/wiki/Blood_transfusionhttp://en.wikipedia.org/wiki/Endemic_(epidemiology)http://en.wikipedia.org/wiki/World_War_II -
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C. HISTORY OF PRESENT ILLNESSJanuary 7, 2011, Friday, 8 days Prior to Admission, the patient is at Quaipo, he
attended a mass like he always do every Friday. After the mass, he ate fishballs at the
street and drink water.
January 8, 2011, 7 days prior to admission, the patient experience increased in
body temperature. He managed it by drinking Paracetamol every 4 hours.
January 9, 2011, the patient is at Luneta because he will participate in the feast
of Nazareno, the patient is a devotee that is why even though he is not feeling well, he
still attended the parade. And on that day, according to the patient, it also rained.
January 10, 2011, the patient decided to seek consultation to a clinic at San Jose
Del Monte Bulacan, he was advised to have a Complete Blood Count, and the result
says that he has a decrease in platelet count. The doctor prescribed Paracetamol every
4 hours and Oral rehydration solution for 3 days.1 day prior to admission, the patient is afebrile, with epigastric pain and (+) LBM,
he seeks consultation at the Jose Reyes Hospital and then decided to transfer at San
Lazaro Hospital and was admitted. Admission Diagnosis was Typhoid Fever vs Dengue
F
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Before the onset of the disease, the patients sleep pattern is, he is sleeping early
in the evening like between 7:00 PM-08:00PM and wakes up about 4:00 in the morning.
According to him, he was not able to sleep after that. After the onset of the disease,
there is an alteration in his sleeping pattern because of the discomfort he is
experiencing.
I. SOCIAL DATA
The patient has good relationship with his family. They are able to bond and be
happy sometimes although there are problems. His support system is his children that
are sometimes giving him money to be able to use for their daily living.
J. EDUCATIONAL HISTORY
The patient is a highschool graduate.
K. OCCUPATIONAL HISTORY
The patient is a tricycle driver, and since the onset of the disease, he was not
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II. Skin
The patient skin is dark brown in color. Skin is warm to touch with a
temperature of 36.7C, slightly dry in skin folds. There is a decreased in skin
turgor and dry skin.
There is a decreased in skin turgor and dry skin because of decreased fluid
in the body of the patient related dehydration because of the disease process.
III. Hair
The hair of the patient is black, evenly distributed and covers the whole
scalp. The hair is not oily, thick and shiny. No infections or infestations noted, the
amount of body hair is variable.
IV. Nail
The shape of the nail is convex curvature 160 degrees, the texture is
smooth and has intact epidermis. The nail bed is pinkish in color and the nails
color prompt return in less than 3 seconds while performing the blanch test
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external ear canal inspection revels that there is a minimal amount of cerumen,
no lesions, pus or blood present.
For the nose, the external nose is symmetric and straight, the septum is
straight, the color of the nose is as the same as the skin color. The sinuses are
not tender and air moves freely while client breathe through the nares.
VI. Mouth and oropharynx
For the mouth assessment reveals that the lips is pinkish, moist and
smooth, the teeth is well aligned with no filling. The gums are pinkish, moist and
no swelling. The tongue is slightly rough on top and symmetrical; the frenulum is
straight and is at the midline. The mouth floor is pinkish and moist. The hard and
soft palate is pinkish and moist. The uvula is symmetrical, the tonsils are
symmetrical, no discharge and non-inflamed. The gag reflex is present. No
bleeding gums, no sore tongue, dry mouth or frequent sore throats.
VII. Neck
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XI. Abdomen
The patient is not experiencing LBM, not vomiting. The patient is not
experiencing trouble in swallowing, heartburn, nausea. The patient is not
experiencing abdominal pain, food intolerance, or excessive belching or passing
of gas. No gallbladder trouble and hepatitis.
XII. Musculoskeletal
The clients muscle, joints, and bones are not swelling. Not tender uponpalpation.
XIII. Gross motor
The client able to perform passive ROM exercise, and is ambulatory He can sit,
d t d d h lk t f t Th li t bl t id tif d f
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PERSON GORDON APPROACH
PSYCHOLOGICALI. Self perception Self-concept pattern:
QUESTIONS CLIENTS RESPONSE INTERPRETATION
Description of self The patient verbalized that
he is kind, simple, and isreligious.
Patient has a positive self
concept. Self-concept isones mental image ofoneself. The client haspositive self-concept whichare better able too developand maintain interpersonalrelationships.(KOZIERp.1003)
Feeling towards self The patient stated that heis friendly and kind. Andthat he is a positive thinker.
Patient is a positive thinker.Self-esteem is ones
judgment of ones worth,that is, the clientsstandards and
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Support system Siblings The family was able todistribute the roles for each
family member. Role is aset of expectations abouthow the person occupyingone position behaves.(KOZIER p.1006)
Family form andstructure
He is living with his wife;some of his children havetheir own family already.Their support system is herdaughter. Both of them areinvolve in decision making.
Sufficiency income Income of the family is justright for their needs, it issufficient.
The family was able to findways to be able to supplytheir needs with a limitedincome. The greater thenumber of resources aperson has and uses, themore positive the effect onthe self-concept.(KOZIER p.1007)
Structuralcharacteristics (space,privacy, conducivenessduring mealtime)
The patient stated that theyhave sufficient space athome and its comfortable.
Individual resources shouldhave internal and externalstructures. (KOZIERp.1007)
Perceptions feeling The patient describes their The foundation of self
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being.
IV. Cognitive perceptual
Hearing difficulty The patient stated that hedo not have any hearingdifficulty.
Normal sense of hearing.Sensory deficit is impairedreception, perception, orboth, of one or more of thesenses. (KOZIER p.982)
Visual problems The patient stated that hedo not experience anyvisual changes.
Blindness and deafness aresensory deficits.
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Satisfaction with ones life The patient stated that he issatisfied in his life. He
accepts whatever the Lordgives to him.
Although, the patient andhis family has problems, he
is still satisfied with hislife.The sense of identityhas provides a person witha feeling of continuity andunity of personality. Theindividual sees himself asunique (kozier p.1005)
Things and personalvalues; held as important
The patient verbalized thathis family and their health isimportant to him. And alsohis faith to the Lord.
Patient was able to statepersons he held asimportant. The greater thenumber of the resources aperson has and uses, themore positive the effect onthe self concept (kozier
p.1005)
Family/social values thatinfluenced ones life;
The patient stated that hismother influenced him forbeing religious
Ones value are largelyinfluenced by the family andculture (kozier p 1007)
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Bowel elimination pattern The patient verbalized that he movesbowel regularly, before onset of disease,
he defecate at least once a day usually inthe morning. He is not experiencing anydiscomfort during elimination. After theonset of disease, his bowel elimination isaffected because he is experiencing aLBM, his bowel elimination at this time isat least 3x or more a day and is loose.
Urinary elimination pattern Before admission the patients urinaryelimination is at least 5x a day because heis drinking water often. During admission,the patient still has increase in urinaryelimination because of the increase intakeof oral fluids plus the intravenous line toprevent dehydration.
Use of aids The patient do not have difficulty in his
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Sufficiency of energy forcompleting desired
activities
The patient has sufficientenergy in completing his
activities of daily livingbefore his confinement.
Vigorous physical activity isnot always needed to
achievepositive result.(Fundamentals of Nursing5th edition by Taylor, page1117)
Exercise Program The patient is walking everymorning which he considersas his exercise everyday.
Lack of exercise, inactivity,or immobility related toillness, or
injury place a person athigh risk for serious healthproblems.Immobility can affect themajor body systems. Likethe benefits, a
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Circadian rhythms, time,
duration of sleep
The patient sleeps at 8pm,
sometimes 9pm and wakesup at 4 am, and was notable to sleep again so thepatient just start hisactivities of the day.
For no known reason,
8hours of sleep at night hasbeen the acceptedstandard for adults despiteobvious variations seen inthe general population. It isimportant that a personfollows a pattern of rest thatmaintains well being. Many
factors affect a personsability to rest illnesses andvarious life situations thatcauses physiological stresstends to disturb sleep.(Kozier et.al, Fundamentalsof Nursing 7thed. Page 1169-1170).
Use of supportive devices The client stated that hedoes not use supportiveaids to sleep.
Sleep onset problems,dreams and earlyawakenings
The patient experiencedifficulty in sleeping, hecannot sleep continuouslysince he was admitted atthe hospital.
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Allergies The patient does not haveany allergies to any food or
drug.
Allergies should beassessed to be able to
determine which food anddrug is apppropriate for histreatment plan.
Skin integrity
Changes in body
temperature
The clients skin is slightlydry.
The patient is afebrile.
The patients temperature isin normal state.
OXYGENATION
Tolerance with dailyactivities
The patient was able toperform activities of dailyliving without any difficultyon breathing or shortnessof breath.
Oxygenation status shouldbe assessed to determinethe need of oxygen therapywhen needed especiallyduring continuous works.
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Food/fluid preference The patient stated that, heis not eating pork meats,and foods rich in uric acidlike monggo beans andalso fat-rich foods. He isusually eating fried fish athoise.
According to the foodpyramid, the patient wasable to eat right foods thatis needed by the body, hewas able to eat foods inmoderation. An adequatefood intake consists ofbalance essentials
nutrients:water, carbohydrates, fats,proteins, vitamins andminerals. Habitsabout eating are affected bymany factors like financial
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Degree of appetite and
what seems to stimulateand dampen it
Delicious smell of food
often stimulate the patientsappetite, and when he seesmeat, it dampens hisappetite.
II. CASE DESCRIPTIONDIAGNOSTIC PROCEDURES
Hematology
It is a screening test used to diagnose and manage numerous diseases. The
results can reflect problems with fluid volume/ loss of blood. This test can reveal
problems with fluid volume/ loss of blood. The test can reveal problems with red blood
cell production and destruction or help diagnose infections, allergies, and problem with
blood clotting.
Nursing Responsibilities:
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The CBC provides valuable information about the blood and to some extent
the bone marrow, which is the blood-forming tissue. The CBC is used for the
following purposes:
as a preoperative test to ensure both adequate oxygen carrying capacity
and hemostasis
to identify persons who may have an infection
to diagnose anemia
to identify acute and chronic illness, bleeding tendencies, and white blood
cell disorders such as leukemia
to monitor treatment for anemia and other blood diseases
to determine the effects of chemotherapy and radiation therapy on blood
cell production
How Test is performed:
Blood is drawn from a vein, usually from the inside of the elbow or the back of the
hand The puncture site is cleaned with antiseptic An elastic band is placed around the
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01/16/11 01/15/11
WBCRBCHemoglobinHematocritMCVMCHMCHCPlatelet
RDWNeutrophilLymphocyteEosinophilMonocyteBasophils
18.824.4812.2837.5883.8227.3832.67309
15.178.611.11
35.61.7
16.734.0411.6
35.5888.0928.7232.6277
12.8479.112.71.261
4.8-10.8 10^9/L4.7-6.1 10^12/L
13-17 g/L40-52 %82-98 fl
28-33 pg33-36 10^9/L150-400 %
11.4-14.0 %40-70 %19-48 %2-8 %3-9 %0-5 %
All cell type is wnormal range exceptwhite blood cells whicincrease in number may indicate presencinfection.
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SGOT/AST 15.00 0.00-31.00 u/L NORMAL
SGPT/AST 11.00 0.00-41.00 u/L NORMAL
Alk. 326.00 53.00-128.00 u/L Increase in normal valuesAlkaline in blood
Phosphatase --- --- ----
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III. DRUG STUDY
Brand name/Generic name
Dosage,Route,
Administration
Action Indication Side Effect Contraindication Nursing considerat
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Acetaminophen(Paracetamol)
Adult and child:>12 yrs old:PO/RECT 325-650 mg q4hprn, max4g/dayChild: PO 10-
15 mg/kg q4h
May block the painimpulsesperipherally thatoccur in responseto inhibition ofprostaglandinsynthesis; does not
possess anti-inflammatoryproperties;antipyretic actionresults frominhibition ofprostaglandins inthe CNS(hypothalamicheat-regulatingcenter)
Symptomatic relief ofpain and fever. Reliefof headache,toothache, backpain,dysmenorrheal,myalgias,neuralgias, etc.
Analgesics and antipyretic for patientshypersensitive toaspirin
Hema: leukopenina,neutropenia,hemolytic anemia,thrombocytopenia,pancytopeniaCNS: stimulations,drwosiness
GI: nausea,vomiting, abdominalpain, hepatotxicity,hepatic seizureInteg: rash, urticariaGU: renal failure
Hypersensitivity,intolerance totartazine (yellowdye #5), alcohol,table sugar,saccharin,depending on the
product.
Assess for liverfunction studies: ASALT, bil irubin,creatinine prior totherapy
Renal function stud
Administer with foomilk to decreasegastric symptom ifneeded
Teach patient not texcess recommendosage
Instruct patient sigof toxicity to drug:nausea, vomiting,abdominal pain, anrefer to the prescri
Notify prescriber ofpain or fever lastinover 3 days.
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Brand name/Generic name
Dosage,Route,
Administration
Action Indication Side Effect Contraindication Nursing considerat
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Cefixime 10 mg 3caps BID
Renal dose:CCr 21-60ml/min give 75% of dose,CCr 50 kg or>12 yrs: Pouse adultdosageChild
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Brand name/Generic name
Dosage, Route,Administration
Action Indication Side Effect Contraindication Nursing consideration
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Furosemide 20mg IV STAT
Adult: O 20-80mg/day in AM maygive another dose in6hr up to 600 mg/dayIM/IV: 20-40 mg,increased 20mg q2h
until desired responseChild: PO/IM/IV:2mg/kg may increaseby 1-2 mg/kg q6h-8hup to 6 mg/kg
Inhibitsreabsorption ofsodium andchloride at proximaland distal tubuleand in the loop of
Henle.
Pulmonary edema,edema in CHF, liverdisease, nephroticsyndrome, ascites,hypertension
CNS:headache,fatigue,weakness,vertigo,paresthesia
CV:orthostatichypotension,chest painEENT: loss ofhearing, earpain, tinnitusELECT:hypokalemia,hypochloremic alkalosis,hypomagnes
emia,hyperurecemia,hypocalcemia,hyponatremia, metabolicalkalosis
Hypersensitivity tosulfonamides,anuria,hypovelomia,infants, lactation,electrolyte
depletion
Assess for signs ofmetabolic alkalosis:drowsiness,restlessness
Signs of hypokalemiapostural hypotension
malaise, fatigue, legcramps, tachycardia
Instruct patient to eatfoods rich inpotassium
Assess for vital signsbefore administration
Laboratory studiesbefore administrationof medication
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Brand name/Generic name
Dosage, Route,Administration
Action Indication Side Effect Contraindication Nursing consideration
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Amlodipine5mg/tab OD
Angina:Adult: PO 5-10 mg qdHypertension:Adult: PO 5 mg qdinitially, max 10mg/day
Inhibits calcium ioninflux across cellmembrane duringcardiacdepolarization;produces relaxation
of coronaryvascular smoothmuscle, peripheralvascular smoothmuscle, dilatescoronary vasculararteries, increasemyocardial oxygendelivery in patientswith vasospasticangina.
Chronic stableangina pectoris,hypertension,vasospastic angina(Prinzmetalsangina); may
coadminister withotherantihypertensives,antianginals.
CV:dysrhythmia,edema,bradycardia,hypotension,palpitations,
syncope, AVblockGI: nausea,vomiting,diarrhea,gastric upset,constipation,abdominalcramps,anorexiaGU: nocturia,polyuria
INTEG: rah,pruritus,urticaria, hairlossCNS:headache,fatigue,dizziness,anxiety,depression
Sick sinussyndrome, 2nd or 3rd
degree heart block,hypotension lessthan 90mmHgsystolic,
hypersensitivity
Assess for vital signsbefore administrationof the medication
Record the I&O
Instruct the patient totake the drug as
prescribed, do notdouble or skip dose
Instruct patient toavoid hazardousactivities untilstabilized on drug,dizziness is no longea problem
Instruct patient tochange positionslowly to prevent
orthostatichypotension
Instruct patient tocontinue good oralhygiene.
III. NURSING CARE PLAN
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Cues Diagnosis Scientificexplanation
Planning Implementation Rationale
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Subjective:
Nilalagnat atnanghihina poako. as verbalizedby the patient.
Objective: Weakness andirritability.
flushed skin
Skin Warm totouch.
Febrile
Restlessness.
Vital Signs takenas follows:(Admitting vitalsigns)T: 38.1CP: 80 bpmR: 17 cpmBP: 130/80 mmHg
Hyperthermiarelated toincreasedmetabolicrate and diseaseprocess.
Aedes Aegypti
Dengue Virus
IgG adheres tothe platelet
(initiates
destructionof the platelet)
thrombocytopenia(50,000/mm3 or
less)
Increased potentialfor hemorrhage
(epistaxis)
stimulates
intenseinflammatory
response
petechial rash,high fever,headache
Short-term goal:After 4 hours ofnursing interventionsthe patient will be ableto:
List ways on howto maintain body
temperature Demonstrate
techniques on howto lower bodytemperature
Take medicationsthat can lowerbody temperature.
Long-term goalAfter 4 days ofnursing interventionsthe patient will be ableto maintain core bodytemperature withinnormal range.
Independent:
Establish rapport with thepatient and patients relative
Note chronological anddevelopmental age
Monitor temperature
Monitor BP
Monitor heart rate andrhythm.
Monitor respirations
Note presence or absenceof sweating
Advise increase fluid intake.
Encourage TSB.
Loosen clothing
To gain the trust andcooperation
Children are moresusceptible to heatstroke
To have baseline data.
Central hypertension orperipheral/posturalhypotension may occur.
Dysrhythmias and ECGchanges are common.
Hyperventilation may bepresent.
Evaporation is decreasedby environmental factors ofhigh humidity.
To prevent dehydration.
To promote heat loss byevaporation andconduction.
To promote heat loss byradiation and conduction.
Aftnuintpato:
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Provide cool environmentand/or fan.
Put local ice packs or wettowels areas of high bloodflow, especially groin and
axillae.
Provide hypothermiablankets.
Maintain bed rest
Monitor and record I and O
Dependent:
Administer meds asordered, antipyretics and/orantibiotics.
Administer fluidreplacement as indicated bythe physician.
Interdependent:
Provide high-calorie diet,tube feeding, parenteralnutrition.
To promote heat loss byconvection.
To promote heat loss.
To minimize shivering.
To reduce metabolicdemands/oxygenconsumption.
For baseline data.
To lower temperature.
To support circulatingvolume and tissueperfusion.
To meet increasedmetabolic demands.
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Cues Diagnosis Scientificexplanation
Planning Implementation Rationale
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Subjective:
Objective:
Weakness andirritability.
Restlessness.
Vital Signs takenas follows:(Admitting vitalsigns)T: 38.1CP: 80 bpmR: 17 cpmBP: 130/80 mmHg
Injury, risk forhemorrhagerelated to alteredclotting factor.
Aedes Aegypti
Dengue Virus
IgG adheres tothe platelet
(initiates
destructionof the platelet)
thrombocytopenia(50,000/mm3 or
less)
Increased potentialfor hemorrhage
(epistaxis)
stimulates
intenseinflammatory
response
petechial rash,high fever,headache
After 4 hrs. Of nursinginterventions, theclient will be able todemonstratebehaviors that reducethe risk for bleeding.
Independent:
Perform thoroughassessments regardingsafety issues when planningfor client care.
Assess for signsand symptoms ofG.I bleeding.Check for secretions.Observe colorand consistency of stools orvomitus.
Position the client onupright position with headtilted slightly forward.
Using your fingers applypressure to the sides of thenose.
Apply nasal pack or coldcompress.
Observe forpresence of
petechiae, ecchymosis,bleeding from one more
Failure to accuratelyassess and intervene orrefer these issues canplace the client at needlessrisk and creates negligenceissues for healthcare
practitioner.
The G.I tract(esophagus andrectum) is themost usualsource of bleeding of itsmucosal fragility.
To minimize the amountof blood pressure on nasal
vessels and to keep bloodmoving forward, not backto the nasopharynx.
To minimize or stopbleeding.
To minimize or stopbleeding.
Sub-acute disseminated
Intravascular coagulation(DIC) maydevelop
Anuintclieto dbered
for
T
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sites.
Monitor pulse,Blood pressure.
Note changes inmentation and level ofconsciousness.
Avoid rectalTemperature.
Encourage use of softtoothbrush, avoidingstrainingfor stool, and forceful nose
blowing.
Use small needles forinjections. Apply pressure tovenipuncture sites for longerthan usual.
Recommend avoidance ofaspirin containing products.
Dependent:
Administer medications and
infusions as prescribed andby using 5 rights system
secondary to alteredclotting factors. An increase inpulse with decreasedBlood pressure canindicateloss of circulating blood
volume. Changes mayIndicate cerebral perfusionsecondary to hypovolemia,hypoxemia.
Rectal vessels are mostvulnerable to rupture.
In the presence ofclotting factor disturbances,minimal trauma can cause
mucosal bleeding.
Minimizes damage totissues, reducing risk forbleeding and hematoma.
Prolongs coagulation,potentiating risk of hemorrhage.
To treat the underlying
cause of the disease.
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(right patient, rightmedication, right route, rightdose,right time)
Interdependent:
Monitor Hgb andHct and clotting factors.
Indicators of anemia,activebleeding, or impendingcomplications.
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