Nursing Diagnosis: Bleeding
Definition of Bleeding
Risk Factors of 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
Nursing Care Plan for Bleeding | Assessment of Bleeding
Nursing Diagnosis for Bleeding | Assessment Focus of Bleeding; Suggested NOC Outcomes of Bleeding
Assessment Focus | Nursing Care Plan for Bleeding (Refer to comprehensive assessment parameters.)
- Cardiac function
- Fluid and electrolytes
- Pharmacologic function/treatments
- Reproduction
- Tissue perfusion
Expected Outcomes | Nursing Diagnosis for Bleeding
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 | Nursing Diagnosis for Bleeding
Maternal Status: Antepartum; Postpartum; Blood Coagulation; Blood Loss Severity; Circulation Status; Vital Sign; Fluid Balance; Electrolyte & Acid Base Balance; Tissue Perfusion: Cellular
Nursing Care Plan for Bleeding | Nursing Interventions of Bleeding
Nursing Care Plan for Bleeding | Nursing Interventions of Bleeding and Rationales; Suggested NIC Interventions of Bleeding
Nursing Interventions of Bleeding and Rationales
- 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.
- 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.
- 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.
- 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.
- 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 | Nursing Diagnosis for Bleeding
Bleeding Precautions; Bleeding Reduction Uterus, Gastrointestinal; Blood Products Administration; Circulatory Precautions; Fluid/Electrolyte Management; Risk Identification; Teaching Prescribed Medications; Vital Sign Monitoring.
This is a sample of Nursing Care Plan for Bleeding.