Nursing diagnosis – risk for bleeding

Risk for bleeding
DEFINITION
At risk for a decrease in blood volume that may compromise health
RISK FACTORS
• RISK FOR BLEEDING
• Pregnancy-related
complications (e.g., placenta
praevia or abruptio)
• Postpartum complications (e.g.,
uterine atony, retained placenta)
• Treatment-related side effects
(e.g., surgery, medications
affecting the bleeding and
clotting, administration of
platelet-deficient blood products,
chemotherapy)
• Circumcision
• Disseminated intravascular
coagulopathy
• Inherent coagulopathies (thrombocytopenia,
hemophilia)
• GI disorders (e.g., gastric
ulcers, polyps, varices)
• Aneurysm
• Impaired liver function (e.g.,
cirrhosis, hepatitis)
• Trauma or history of falls
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Cardiac function
• Fluid and electrolytes
• Pharmacologic function/treatments
• Reproduction
• Tissue perfusion
EXPECTED OUTCOMES
The patient will
• Receive screening to alert about existing risk factors for bleeding.
• Receive follow-through intervention.
• Receive appropriate clinician staffing and surveillance for a rapid
response to rescue the patient before serious bleeding occurs.
• Maintain heart rate, rhythm, blood pressure, and tissue perfusion
within expected ranges during episodes of risk.
• Identify and avoid risk situations with potential for trauma injury.
SUGGESTED NOC OUTCOMES
Maternal Status: Antepartum; Postpartum; Blood Coagulation; Blood
Loss Severity; Circulation Status; Vital Sign; Fluid Balance;
Electrolyte & Acid Base Balance; Tissue Perfusion: Cellular
INTERVENTIONS AND RATIONALES
Determine: Interview/screen each individual for risk factors for bleeding;
some individuals know of their risks for bleeding, whereas others
do not. Assessment findings may indicate need for protective measures.
Anticipate conditions and episodes of care that may precipitate
bleeding especially in high-risk patient care areas to provide early
intervention. Monitor physiologic responses for values that exceed
expected or normal ranges; early bleeding compensatory mechanisms
alter respirations, pulse, and blood pressure and may be present as
subtle changes. Monitor for occult and for frank bleeding—urine,
feces, wounds, and dressings—by visual inspection or point-of-care
testing to identify need for intervention.
Perform: Correlate findings, risk factors, and current episode of care and
patient condition to determine the imminent level of risk for bleeding.
Perform vital signs and basic physical assessments for the patient
who is at risk for bleeding until assured the risk is past to provide
data needed for early intervention. Obtain laboratory tests
(hemoglobin, hematocrit, complete blood cell count, thrombin time,
prothrombin time, activated partial thromboplastin time, etc.) and
point-of-care tests (stool, urine, gastric); these tests provide data that
may be indications of a bleed.
Examine dressings, drainage tubes, and collection canisters for presence
of blood; report findings to support need for changes in therapy.
Inform: Teach patient about intended and unintended effects of medications
(heparin, enoxaparin [Lovenox], warfarin (Coumadin), clopidogrel
[Plavix], aspirin) that increase the risk of bleeding or prolong
clotting. This enables the patient to avoid bleeding-risk situations.
Discuss patterns of risk management to promote a lifestyle that
focuses on health promotion/injury avoidance to diminish injuries.
Discuss alternatives in ADLs to avoid trauma-causing injury and
bleeding.
Attend: Provide care protecting an individual from injury to prevent
bleeding. Implement interventions that reverse or remove the risk of
bleeding or bleeding condition to prevent bleeding or stabilize the
patient’s physiologic condition and assist in recovery.
Provide emotional support to the patient who is bleeding and is
experiencing physiologic compensatory responses of anxiety, fear, and
a sense of dread as this support provides assurance and is calming.
Support participation in decisions about the treatment placing the
patient at risk for bleeding. Active participation encourages fuller
understanding of the rationale and compliance with the treatment.
Manage: Refer to case manager or APN those at risk for bleeding
secondary to treatment (i.e., warfarin INR) for monitoring and
regime adherence. Monitor the recovery of the individual who experienced
a bleeding episode because weakness causes a safety risk for
falls or injury.
SUGGESTED NIC INTERVENTIONS
Bleeding Precautions; Bleeding Reduction Uterus, Gastrointestinal;
Blood Products Administration; Circulatory Precautions; Fluid/Electrolyte
Management; Risk Identification; Teaching Prescribed Medications;
Vital Sign Monitoring
References
Fishbach, F., & Dunning, M. B. (2009). A manual of laboratory & diagnostic
tests (8th ed.). Philadelphia: Lippincott Williams & Wilkins.
McCance, K., & Huether, S. (2006). Pathophysiology: The biologic basis for
disease in adults and children (5th ed.). St. Louis, MO: Mosby.

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