Assessment Diagnosis Planning Intervention Evaluation

Subjective:

Hindi humihinto ang
pagdudugo ng ngipin
niya as verbalized by
the mother.


Objective:
T : 36.4
P : 84
R : 22
B/P : 70/50

Risk for Imbalance
nutrition related to
uncontrolled
gum bleeding


Exhibit no further
signs of bleeding.

Maintain vital signs
within his usual
range.

Maintain an open
airway.

Identify sports and
recreation activities
in which he can
safely
participate.

Verbalize self-care
measures to control
bleeding.


Monitor vital signs and
for further signs of
bleeding.

Assess airway and
auscultate breath sounds.

Instruct patients mother
to help the patient in his
oral hygiene.

Administer medication as
ordered by the doctor to
control bleeding.


After 8hrs of nursing intervention
Patient has no further signs of
bleeding, shock, or
aspiration.






Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:

Hindi humihinto
ang pagdudugo ng
ngipin niya as
verbalized by the
mother.


Objective:
T : 36.4
P : 84
R : 22
B/P : 70/50

Fluid
volume
deficit
related to
loss due to
bleeding.


Indicates
repairs
fluid
balance,
moist oral
mucosa,
skin
turgor
quickly
returned
less than 2
seconds

Monitor
vital signs.

Monitor vital signs.

Monitor output and
income.

Estimate the wound
drainage and the loss of
a visible.

Collaboration in the
provision of adequate
fluid

Changes in vital
signs may indicate
the direction of
abnormal fluid loss
due to an increase
in bleeding /
dehydration.
Need to determine
kidney function,
fluid replacement
needs and to help
evaluate the fluid
status.
Provide
information about
the degree of
hypovolemia and
help determine
intervention.
Maintain fluid
balance due to
bleeding.
Administer
medication as
ordered by the
doctor to control
bleeding.

After 8 hrs of
nursing
intervention the
patient will
experience some
improvement in
his fluid volume.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:

Hindi humihinto ang
pagdudugo ng ngipin
niya as verbalized by
the mother.


Objective:
T : 36.4
P : 84
R : 22
B/P : 70/50

Ineffective tissue
perfusion related
to decrease
hemoglobin
concentration in
the blood
secondary to
blood loss as
manifested by
pallor, pale
palpebral
conjunctive and
weakness and
dizziness.


Monitor Vital
signs.

Oxygen
Administratio
n as
prescribed by
the Physician.

Increase Fluid
Intake.

Administer
Blood
Transfusion
(RBC) as
ordered by the
doctor.

Medications
as ordered by
the doctor.

Encourage patient to have
adequate rest and sleep.

Encourage patient to
increase fluid intake.

Assist patient in her
activities.


Provide quiet and rest full
environment.

To decrease oxygen supply
and demand.



To decrease
consumption of energy
and oxygen.

To increase blood
volume, thereby
enhancing the further
distribution of
nutrients in the blood.

To prevent exhaustion
and energy
congestion.

To conserve energy
and lowers tissue
oxygen demand.

Plan care of activities
with rest periods.

After 8 hrs of
nursing
intervention
the patient
will be able to
demonstrate
improved
tissue
perfusion as
would be
manifested by
pinkish
conjunctiva,
absence of
pallor,
weakness and
dizziness.