Risk for Injury AssessmentPlanningInterventionScientific RationaleEvaluation

Subjective:nanghihina ako lalo na pag naglalakad inaalalayan ako. As verbalized by the patient

Objective:> Decreased strength in lower extremities> Weak in appearance> Limited motion> Headache> DizzinessAfter 8 hours of nursing intervention, the patient will be able to display homeostasis as evidenced by absence of bleeding and will be able to demonstrate techniques in ambulating with assistance.

Avoid injections, rectal temperatures and rectal tubes. Administer rectal suppositories with caution.

Maintain a safe environment. Keep all necessary objects and call bell within patients reach and place bed in low position.

Maintain bed rest or chair rest when platelets are below 10,000 or as individually appropriate. Assess medication regimen.

Hematest body fluids:urine, stool, vomitus, for occult blood.

Observe for or report epistaxis, hemoptysis, hematuria, non menstrual vaginal bleeding, or oozing from lesions or body orifices and/or IV insertion sites.

Monitor for changes in vital signs and skin color: BP, pulse, respirations, skin pallor and discoloration.

Review laboratory studies:PT, aPTT, clotting time, platelets, Hb/Hct.

Administer blood products as indicated.

Avoid use of aspirin products and NSAIDs, especially in presence of gastric lesions.

Protects patient from procedure-related causes of bleeding: insertion of thermometers, rectal tubes can damage or tear rectal mucosa. Some medications need to be given via suppository, so caution is advised.

Reduces accidental injury, which could result in bleeding.

Reduces possibility of injury, although activity needs to be maintained. May need to discontinue or reduce dosage of a drug. Patient can have a surprisingly low platelet count without bleeding.

Prompt detection of bleeding or initiation of therapy may prevent critical hemorrhage.

Spontaneous bleeding may indicate development of DIC or immune thrombocytopenia, necessitating further evaluation and prompt intervention.

Presence of bleeding and hemorrhage may lead to circulatory failure and shock.

Detects alterations in clotting capability; identifies therapy needs. Many individuals (up to 80%) display platelet count below 50,000 and may be asymptomatic, necessitating regular monitoring.

Transfusions may be required in the event of persistent or massive spontaneous bleeding.

These medications reduce platelet aggregation, impairing and prolonging the coagulation process, and may cause further gastric irritation, increasing risk of bleeding.After 8 hours of nursing intervention, the patient was able to display homeostasis as evidenced by bleeding and able to demonstrate ambulating techniques with assistance.