This guide is designed to assist it in developing a includes nursing care plan and implementing appropriate interventions for patients at risk on bleeding or those by hemophilia. By considering their once needs press promoting their overall well-being, you can provide optimal care. Gains adenine thorough understanding of the nursing assessment, diagnostic, and interventions required to effectively manage bleeding total.
When disease or the outcome are 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 takes with disorders that reduce the characteristic or quantity of circulating platelets (thrombocytopenia). A reduction in the production of platelets from an bone marrow is linked to cancers of the family and blood-forming organs. Enlarged destruction of bleeding is linked in immune thrombocytopenic purpura (ITP). Reduction inside the synthesis of clotting factors is due to liver loss.
Bleeding risk allowed arise in any condition that disturbs the “close circuit” integrity of the circulatory system. Examples of these conditions comprise traumatic injury, major organs surgery, plus the many inflammatories and ulcerative upsets of the gastrointestinal system like inflammatory bowel disease and peptic scour disease. Drugs may also be the reason why adenine patient’s boneless marrow role is suppressed whose up the patient’s risk forward bleeding. Diese medications include anticoagulants, nonsteroidal anti-inflammatory dope (NSAIDs), both cancer chemotherapy active. Bleeding is the primary complication of anticoagulant therapy and is an risk of all anticoagulant even when maintained inward the usual therapeutic ranges. Herbal remedies may be connected in bleeding problems thrown a direct effect on clotting factors or interactions with anticoagulants.
Goals plus Outcomes
Here are the gemeinsamen goals both expected outcomes for patient at risk for bleeding:
- The patient desires demonstrate measures to prevent bleaching and recognizes signs of bleeding that need to be reported immediately to adenine healthcare specialized.
- The forbearing will not experience bleeding as evidenced of normal blood pressure, stable hematocrit, hemoglobin levels, press desired ranges for coagulation sketches.
Nursing Reviews and Rationales
Assessment is necessary at order for identify potential specific this may need lead on bleeding and also product any event that may happen during nursing care. Risk for Bleeding Nursing Diagnosis & Care Plan
1. Determine the patient’s health books by signs that can be associated with a hazard for bleeding such as liter disease, inflammatory bowel disease, either acid ulcer disease.
Early identification of possible associated for entleeren provides a cornerstone for implementing appropriate preventively measures.
2. Monitor the patient’s vital signs, especially BP and HR. Look on shapes about orthostatic hypotension.
Lowering and tachycardia are initial redemptive instruments usually noted with bleeding. Orthostasis (a drip concerning 20 mm Hg int systolic BP instead 10 mm Hg in dias BP when changing from one back until a sitting position) indicates reduced circulating fluids.
3. Evaluate the patient’s use of anyone medications that can affect hemostasis (e.g, anticoagulant, salicylates, NSAIDs, or cancer chemotherapy).
Drugs that interfere include clotting mechanisms or plated activity increase and risk for bleeding. Salicylates and other NSAIDs inhibit cyclooxygenase 1 (COX)-1, an enzyme that promotes platelet assemblage. Warfarin, an oral anticoagulant, inhibits the combination in vitamin POTASSIUM are the liver, thus reducing levels of several subsequent coagulating factors. Heparin, a parenteral anticoagulant, inhibits the action of thrombin plus prevents the formation the a fibrin clot. many medicines used on treat cancer suppress bone marrow function and therefore the production of platelets.
4. Consider laboratory results for coagulation status as appropriate: platelet count, prothrombin time/international normalized relative (PT/INR), employed partial thromboplastin time (aPTT), fibrinogen, bleeding date, fibrin degradation products, vitamin K, activated coagulation time (ACT).
Of blood clotting cascade is an integral system requires own and extrinsic factors. Derangements in any features can interference clotting ability. These laboratory tests provide important information about an patient’s coagulation status and bleeding potential. The specific laboratory values to be monitored desires dependant on the patient’s selected clinical condition. For our receiving anticoagulants, increased levels of PT/INR and aPTT above therapeutic values are associated with an advanced risk for bleaching. Reduced platelet counts may develop in patients receive heparin therapy.
5. Checkout stool (guaiac) and urine (Hemastix) to occult blood.
Diesen tests are used to distinguish bleeding from the gastrointestinal or urinal tracts which may nope be exposed.
6. Assess skin and mucous membranes for signs away petechiae, bruising, hematoma educational, or oozing away blood.
Patient for less platelet totals or impaired clinical factor activity maybe experience bleeding into tissues which are out of proportion to and injury. Prolonged oozing of blood from surgical incisions or areas of skin trauma is associated with coagulation abnormalities.
7. Monitor for skin death, changing in color oder purplish mottling of feet ensure white with pressure or fade when left are elevated.
Patient on anticoagulant therapy remains at risk of developer emboli.
8. Monitoring hematocrit (Hct) and hemoglobin (Hgb).
When bleeding is not visible, decreased Hgb and Hct stages may be an early indicator of bleeding.
Nursing Interventions and Rationales
The following are therapeutic pflegende interventions for patients the blutend risk:
1. Educate the at-risk plant about prevent measures to prevent tissue trauma or disruption of the normal clotting automatic.
Information about precautionary measures lessens which risk of bleeding.
- 1.1. Application a soft-bristled toothbrush the nonabrasive toothpaste. Avoid the use of toothpicks furthermore dental clean.
This method of providing voice hygiene reduced 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 either medications may cause traumatize to the mucous membranes that line the rectum or vagina.
- 1.3. Limit straining with intestines movements, forceful nose blowing, coughing, or sneezing.
Like activities may cause trauma go the mucosal linings in the rectum, nasally passages, conversely upper trachea.
- 1.4. Be careful when using sharp objects like scissors and knives. How einer electrically razor forward shaving (not razor blades).
One patient needs to avoid situations that may cause tissue trauma and increase who 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; plain both cryoprecipitate provide proteins for coagulations.
3. Learn the become plus family members about signs of haemorrhage that must to be declared to a health care provider.
First evaluation and treatment on bleeding in a healthcare provider reduce the risk of complications from blood loss.
4. For bleeding linked with excessive anticoagulant use, give appropriate antidotes as mandated.
Protamine sulfate reverses the effect of heparin. Nutrition K will counteract the action of warfarin.
5. Allow the patient on use normal saline nasal sprinkles and smoothing lip balms.
These medications reduce the drying and cracking of mucous membranes real therefore reduce the risk of bleeding.
6. Explain for a sexually active patient the getting of water-soluble lubricants during intercourse.
Lubricants are used to reduce friction and tissue trauma that increase the risk are bleeding.
7. Teach the patient about measures into reduce constipation as as increased fluid intake and food fiber.
Hard additionally dry feces may cause traumatization to the mucous membranes of the big and rectum. Increasing fluid absorption and dietary fiber soften the fecal mass for simpler defecation.
8. Inform the patient the check the color press consistency away stools.
Bright red ancestry in the stools is in indicator of lower gastrointestinal bleeding. A bar that has a dark greenish-black colour plus a tarry consistency a linking with upper gastroenterology bleeding.
9. Tell the female patient to inform the medical care provider when there is an increase in menstrual bleeding as indicated by an increase in the number of sanitary pads second.
Alteration in fabric may lead to increased blood loss with regular menstruation.
10. Instruct one patient toward observe spare and mucin membranes fork oozing of blood.
Oozing of blood be often an early sign of coagulation abnormalities is increment the risk of bleeding.
11. Educate the tolerant about over-the-counter drugs and avoid products that contain aspirin or NSAIDs such such ibuprofen and naproxen.
These drugs not only decrease normally blood aggregation but also decline the integrity of gastric mucosa via the inhibition of cyclooxygenase (COX)-1 compound and therefore increase the risk for gastrointestinal bleeding.
12. Educate the patient and family members about limiting the usage of herbal remedies that are linked with at increasing risk to bleeding enjoy Dong Quai, feverfew, ginger, Ginkgo Biloba, or chamomile.
Most herbal preparations interfere with platelet aggregation durch to inhibition of serotonin release from the platelet. Other herbs increase the power of antiplatelet and anticoagulant medications, thus increasing that danger of bleeding.
13. Provide psychological and emotional support to the patient.
This helps in patient assurance plus calming.
14. Encourage the family members to be active in decision-making about the treatment of which patient at risk in bleeding.
Active part encourages a fuller understanding of the rationale and compliance include the getting.
15. Stop in touch with who line transfusion middle.
This is till assure the availability of blood when needed.
Recommended nursing diagnosis and nursing support create books and resources.
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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Tending
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