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The UWI School of Nursing, Mona Nursing Care of Adults Clinical Practicum NURS 2214 Individual Care Plan Document

After receiving nursing care and interventions for 8 hours, the patient's skin will not show any signs of bleeding such as blood in stool, saliva, or bruising. The nursing student will monitor the patient for bleeding every 2-4 hours, educate them on checking for bleeding, encourage soft toothbrushing and avoiding dental flossing. Laboratory tests and vital signs will also be monitored regularly to assess the patient's coagulation status and detect any potential bleeding issues.

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Giovanni Martin
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49 views3 pages

The UWI School of Nursing, Mona Nursing Care of Adults Clinical Practicum NURS 2214 Individual Care Plan Document

After receiving nursing care and interventions for 8 hours, the patient's skin will not show any signs of bleeding such as blood in stool, saliva, or bruising. The nursing student will monitor the patient for bleeding every 2-4 hours, educate them on checking for bleeding, encourage soft toothbrushing and avoiding dental flossing. Laboratory tests and vital signs will also be monitored regularly to assess the patient's coagulation status and detect any potential bleeding issues.

Uploaded by

Giovanni Martin
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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The University of the West Indies

The UWI School of Nursing, Mona

Nursing Care of Adults Clinical Practicum NURS 2214


INDIVIDUAL CARE PLAN DOCUMENT

GROUP ASSIGNED ___________________________________________________________ DATE ________October 22, 2018__________________


STUDENTS’ ID 620042100
CLIENT’S INITIALS____________________________________________________
CLIENT’S PRIMARY DIAGNOSIS___________________________________________Leukemia____________________

Assessment Data Nursing Diagnosis Patient’s Outcome Interventions Rationales Evaluation


Subjective/Objectives
After 8hrs of nursing 1. Monitor patient for 1.This is done to After 6hrs following
Risk for bleeding related and collaborative signs of bleeding in the ensure that the nursing and collaborative
Subjective Data to decreased blood cells( care patient skin will saliva, oral mucosa, stool, patient is having no interventions patient will
chemotherapy treatment) not have any signs of ecchymosis every 2-4 bleeding. not have any signs of
bleeding as evidenced hours. bleeding as evidenced by
by no blood in stool, no blood in stool, saliva,
saliva, pt levels 2. Educate patient on the 2. This is done to PT within range of 11-20
within normal range importance of checking ensure that if seconds, PTT 25-35
11-20 seconds, PTT for any signs of bleeding. bleeding occurs it is seconds, platelet levels
levels 25-35 seconds, notified to the health 150-450*10^9L.
platelet levels 150- team in a timely
Objective Data 450*10^9L. manner.

Pt? 3. Encourage the use of a 3. This is done so as


Ptt? soft toothbrush and avoid to prevent easy
Platelet? dental flossing. bruising that may
Rbc levels ? result in bleeding.

4. Monitor patient’s PT, 4. These laboratory


PTT, Platelet levels as values are important
ordered. in proving
information on the
patient’s coagulation
status and bleeding
potential.
5. Monitor patient’s vital 5. Hypotension and
signs especially the Bp and tachycardia are
pulse rate every 4 hours. initial compensatory
mechanisms for
bleeding.

6. Administer packed 6. This aids in


RBC’s as ordered. replacing the blood
clotting factors.

Assessment Data Nursing Diagnosis Patient’s Outcome Interventions Rationales Evaluation


Subjective/Objectives

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