This guide is designed to assist you in developing a comprehensive nursing care plan and implementing appropriate interventions for patients at risk for bleeding or those with hemophilia. By considering their unique needs and promoting their overall well-being, you can provide optimal care. Gain a thorough understanding of the nursing assessment, diagnosis, and interventions required to effectively manage bleeding risk.
When disease or the outcome of disease treatments confuse the standard mechanisms that maintain hemostasis, a patient may be at risk for bleeding. Certain diseases like hemophilia interfere with the genetic expression of normal clotting factors. Risk for bleeding happens with disorders that reduce the quality or quantity of circulating platelets (thrombocytopenia). A reduction in the production of platelets from the bone marrow is linked to cancers of the blood and blood-forming organs. Increased destruction of platelets is linked to immune thrombocytopenic purpura (ITP). Reduction in the synthesis of clotting factors is due to liver impairment.
Bleeding risk may arise in any condition that disturbs the “close circuit” integrity of the circulatory system. Examples of these conditions include traumatic injury, major organ surgery, and the many inflammatories and ulcerative disorders of the gastrointestinal system like inflammatory bowel disease and peptic ulcer disease. Drugs may also be the reason why a patient’s bone marrow function is suppressed which increases the patient’s risk for bleeding. These drugs include anticoagulants, nonsteroidal anti-inflammatory drugs (NSAIDs), and cancer chemotherapy agents. Bleeding is the primary complication of anticoagulant therapy and is a risk of all anticoagulants even when maintained within the usual therapeutic ranges. Herbal remedies may be connected to bleeding problems through a direct effect on clotting factors or interactions with anticoagulants.
Goals and Outcomes
Here are the common goals and expected outcomes for patient at risk for bleeding:
- The patient will demonstrate measures to prevent bleeding and recognizes signs of bleeding that need to be reported immediately to a healthcare professional.
- The patient will not experience bleeding as evidenced by normal blood pressure, stable hematocrit, hemoglobin levels, and desired ranges for coagulation profiles.
Nursing Assessment and Rationales
Assessment is necessary in order to identify potential problems that may have lead to bleeding and also name any event that may happen during nursing care.
1. Determine the patient’s health history for signs that can be associated with a risk for bleeding such as liver disease, inflammatory bowel disease, or peptic ulcer disease.
Early identification of possible risks for bleeding provides a foundation for implementing appropriate preventive measures.
2. Monitor the patient’s vital signs, especially BP and HR. Look for signs of orthostatic hypotension.
Hypotension and tachycardia are initial compensatory mechanisms usually noted with bleeding. Orthostasis (a drip of 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP when changing from a supine to a sitting position) indicates reduced circulating fluids.
3. Evaluate the patient’s use of any medications that can affect hemostasis (e.g, anticoagulants, salicylates, NSAIDs, or cancer chemotherapy).
Drugs that interfere with clotting mechanisms or platelet activity increase the risk for bleeding. Salicylates and other NSAIDs inhibit cyclooxygenase 1 (COX)-1, an enzyme that promotes platelet aggregation. Warfarin, an oral anticoagulant, inhibits the synthesis of vitamin K in the liver, thus reducing levels of several subsequent clotting factors. Heparin, a parenteral anticoagulant, inhibits the action of thrombin and prevents the formation of a fibrin clot. many drugs used to treat cancer suppress bone marrow function and therefore the production of platelets.
4. Review laboratory results for coagulation status as appropriate: platelet count, prothrombin time/international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT), fibrinogen, bleeding time, fibrin degradation products, vitamin K, activated coagulation time (ACT).
The blood clotting cascade is an integral system requiring intrinsic and extrinsic factors. Derangements in any factors can affect clotting ability. These laboratory tests provide important information about the patient’s coagulation status and bleeding potential. The specific laboratory values to be monitored will depend on the patient’s specific clinical condition. For patients receiving anticoagulants, increased levels of PT/INR and aPTT above therapeutic values are associated with an increased risk for bleeding. Reduced platelet counts may develop in patients receiving heparin therapy.
6. Assess skin and mucous membranes for signs of petechiae, bruising, hematoma formation, or oozing of blood.
Patients with reduced platelet counts or impaired clotting factor activity may experience bleeding into tissues that are out of proportion to the injury. Prolonged oozing of blood from surgical incisions or areas of skin trauma is associated with coagulation abnormalities.
7. Monitor for skin necrosis, changes in blue or purple mottling of feet that blanch with pressure or fade when legs are elevated.
Patient on anticoagulant therapy remains at risk of developing emboli.
8. Monitor hematocrit (Hct) and hemoglobin (Hgb).
When bleeding is not visible, decreased Hgb and Hct levels may be an early indicator of bleeding.
Nursing Interventions and Rationales
The following are therapeutic nursing interventions for patients with bleeding risk:
1. Educate the at-risk patient about precautionary measures to prevent tissue trauma or disruption of the normal clotting mechanisms.
Information about precautionary measures lessens the risk of bleeding.
- 1.1. Use a soft-bristled toothbrush and nonabrasive toothpaste. Avoid the use of toothpicks and dental floss.
This method of providing oral hygiene reduces trauma to oral mucous membranes and the risk of bleeding from the gums.
- 1.2. Avoid rectal suppositories, thermometers, enemas, vaginal douches, and tampons.
These invasive devices or medications may cause trauma to the mucous membranes that line the rectum or vagina.
- 1.3. Limit straining with bowel movements, forceful nose blowing, coughing, or sneezing.
These activities may cause trauma to the mucosal linings in the rectum, nasal passages, or upper airways.
- 1.4. Be careful when using sharp objects like scissors and knives. Use an electric razor for shaving (not razor blades).
The patient needs to avoid situations that may cause tissue trauma and increase the risk of bleeding.
2. Administer blood products if indicated.
Blood product transfusions replace blood clotting factors; RBCs increase oxygen-carrying capacity; FFP replaces clotting factors and inhibitors; platelets and cryoprecipitate provide proteins for coagulations.
3. Educate the patient and family members about signs of bleeding that need to be reported to a health care provider.
Early evaluation and treatment of bleeding by a healthcare provider reduce the risk of complications from blood loss.
4. For bleeding linked with excessive anticoagulant use, give appropriate antidotes as prescribed.
Protamine sulfate reverses the effect of heparin. Vitamin K will counteract the action of warfarin.
5. Allow the patient to use normal saline nasal sprays and emollient lip balms.
These treatments reduce the drying and cracking of mucous membranes and therefore reduce the risk of bleeding.
6. Explain to a sexually active patient the use of water-soluble lubricants during intercourse.
Lubricants are used to reduce friction and tissue trauma that increase the risk of bleeding.
7. Teach the patient about measures to reduce constipation such as increased fluid intake and dietary fiber.
Hard and dry feces may cause trauma to the mucous membranes of the colon and rectum. Increasing fluid intake and dietary fiber soften the fecal mass for easier defecation.
8. Inform the patient to check the color and consistency of stools.
Bright red blood in the stools is an indicator of lower gastrointestinal bleeding. A stool that has a dark greenish-black color and a tarry consistency is linked with upper gastrointestinal bleeding.
9. Tell the female patient to inform the health care provider when there is an increase in menstrual bleeding as indicated by an increase in the number of sanitary pads used.
Alterations in coagulation may lead to increased blood loss with regular menstruation.
10. Instruct the patient to observe skin and mucous membranes for oozing of blood.
Oozing of blood is often an early sign of coagulation abnormalities that increase the risk of bleeding.
11. Educate the patient about over-the-counter drugs and avoid products that contain aspirin or NSAIDs such as ibuprofen and naproxen.
These drugs not only decrease normal platelet aggregation but also decrease the integrity of gastric mucosa through the inhibition of cyclooxygenase (COX)-1 inhibitor and therefore increase the risk for gastrointestinal bleeding.
12. Educate the patient and family members about limiting the use of herbal remedies that are linked with an increased risk for bleeding like Dong Quai, feverfew, ginger, Ginkgo Biloba, and chamomile.
Most herbal preparations interfere with platelet aggregation through the inhibition of serotonin release from the platelet. Other herbs increase the effect of antiplatelet and anticoagulant medications, thus increasing the risk of bleeding.
13. Provide psychological and emotional support to the patient.
This helps in patient assurance and calming.
14. Encourage the family members to be active in decision-making about the treatment of the patient at risk for bleeding.
Active participation encourages a fuller understanding of the rationale and compliance with the treatment.
15. Keep in touch with the blood transfusion center.
This is to assure the availability of blood when needed.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.