This article can be used to create a plan of care for a patient with a risk for bleeding. Risk for bleeding is commonly defined as a risk for a decrease in blood volume to an extent that health is jeopardized. Patient outcomes can be improved using risk for bleeding assessments and interventions to prevent and readily identify bleeding complications.
In this article:
- Risk Factors (Related to)
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Risk Factors (Related to)
The following are common risk factors for bleeding:
- Some genetic disorders, liver disease, and certain cancers can interfere with the ability for blood to clot, putting the patient at risk for bleeding.
- Major surgery, trauma, or ulcerative gastrointestinal disorders can all be sources of blood loss. Risk for bleeding can also be associated with pregnancy and postpartum complications.
- Some medications, such as NSAIDs, increase a patient’s bleeding risk as a side effect of the drug.
Identifying the patient’s individual risk factors is crucial to implementing effective risk for bleeding interventions.
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected Outcomes
Care goals for risk for bleeding are focused on prevention of bleeding and patient education. Three expected outcomes for a patient with a risk for bleeding diagnosis are the following:
- Patient does not experience bleeding as evidenced by hemoglobin and hematocrit levels within desired range, PT and INR values within desired range, and blood pressure and heart rate within normal range.
- Patient verbalizes understanding of measures to prevent bleeding.
- Patient verbalizes recognition of signs of bleeding that need to be reported to a healthcare provider.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to risk for bleeding.
1. Assess the patient’s medical history for risk factors or current conditions that could put the patient at risk for bleeding.
Appropriate preventative measures can be implemented by identifying potential risks for bleeding.
2. Review the patient’s medications for drugs that can compromise hemostasis, such as anticoagulants, NSAIDs, or chemotherapy.
Drugs that compromise the body’s ability to clot increase a patient’s risk for bleeding.
3. Monitor vital signs, including blood pressure and heart rate.
Early signs of bleeding are tachycardia and hypotension.
4. Assess periodically and watch for signs of orthostatic hypotension.
Light-headedness or significant blood pressure drops when changing position can indicate reduced blood volume. This also increases the patient’s risk of falling which could cause bleeding.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with a risk for bleeding.
1. Instruct the patient about appropriate risk-reduction interventions.
Using precautionary measures prevents tissue trauma and reduces the risk for bleeding.
- Use a soft toothbrush and do not use dental picks.
- Avoid rectal suppositories, enemas, and thermometers.
- Avoid vaginal douches and tampons.
- Avoid straining with bowel movements.
- Avoid forceful coughing, sneezing, or blowing of the nose.
- Use caution with sharp objects.
- Use an electric razor instead of razor blades.
- Do not play contact sports.
2. Educate the patient and family about signs of bleeding that need to be reported to a healthcare provider.
Early identification and treatment of bleeding can reduce blood loss complications. Educate the family when bleeding becomes a medical emergency.
3. Administer reversal agents or blood products as ordered.
For patients on anticoagulants, reversal agents may be ordered if there is a current bleeding emergency.
- Protamine sulfate is the antidote for heparin.
- Vitamin K is the antidote for warfarin.
Whole blood or blood products may be ordered to replace lost blood volume or blood components. Antidotes will counteract anticoagulants. Blood and blood products replace clotting factors and oxygen-carrying RBCs.
4. Teach the patient to read labels for over-the-counter medications. Instruct them to avoid products that contain aspirin or NSAIDs.
These drugs reduce platelet action and inhibit clotting. They also increase the risk for gastrointestinal bleeding.
Nursing Care Plans
Care plans for bleeding risk should focus on the patient’s specific risk factors and appropriate interventions. Some conditions associated with risk for bleeding are:
- Aneurysm
- Circumcision
- DIC (Disseminated intravascular coagulopathy)
- Gastrointestinal condition
- Impaired liver function
- Inherent coagulopathy, such as hemophilia
- Postpartum and pregnancy complications
- Trauma or surgery
- Medications (anticoagulants) and treatments that can cause bleeding
- Cancer
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for bleeding risk.
Care Plan #1
Diagnostic statement:
Risk for bleeding as evidenced by a deficient knowledge of bleeding precautions.
Expected outcomes:
- Patient will verbalize understanding of bleeding precautions strategies.
- Patient will demonstrate strategies to prevent active bleeding.
Assessment:
1. Assess the patient’s medical history, noting conditions that increase the risk for bleeding (i.e., trauma, peptic ulcer disease, liver disease, etc.).
Identification of the potential risks for bleeding would direct the planning toward appropriate preventive measures.
2. Evaluate the medication regimen.
Medications such as NSAIDs, anticoagulants, and corticosteroids may predispose a patient to bleeding.
3. Assess knowledge about bleeding precautions.
Identifying and prioritizing knowledge needs will help create an effective teaching plan.
Interventions:
1. Instruct the patient about measures to prevent injury.
The following strategies prevent trauma and bleeding to oral mucous membranes.
- Use a soft toothbrush and nonabrasive toothpaste.
- Avoid using toothpicks and dental floss.
- Avoid rectal suppositories, enemas, thermometers, vaginal douches, and tampons.
- Avoid the Vasalva maneuver. Blow your nose, cough, or sneeze gently.
- Avoid any contact sports or sports with a high risk of trauma.
2. Instruct about signs and symptoms of bleeding.
Early identification of active bleeding will reduce the risk of complications.
3. Encourage the patient to read over-the-counter medication labels and advise that excessive use of some medications such as aspirin or NSAIDs (e.g., ibuprofen, naproxen) can cause GI irritation and bleeding.
These drugs decrease normal platelet aggregation and the integrity of gastric mucosa by inhibiting cyclooxygenase, increasing the risk for GI bleeding.
4. Teach the patient and family about using appropriate precautions and safety equipment with daily activities, sports, etc.
These measures reduce the risk of trauma and injury that contribute to the risk of bleeding.
5. Teach the patient and family about measures to control bleeding from superficial skin trauma that bleeds.
The patient and family need to know how to treat bleeding from skin trauma. Application of direct pressure to the site of injury will reduce bleeding. The use of ice packs may reduce hematoma formation and excessive bruising. It is also important to teach the patient when bleeding requires further medical attention or when it is an emergency.
Care Plan #2
Diagnostic statement:
Risk for bleeding as evidenced by altered clotting factors.
Expected outcomes:
- Patient will display normal clotting times:
- Prothrombin time (PT) 11 to 12.5 seconds
- Partial prothrombin time (PTT) 60 to 70 seconds
- Patient will be free from signs of active bleeding:
- Confusion
- Clammy skin
- Dizziness or lightheadedness
- Hypotension
- Pallor
- Tachycardia
- Shortness of breath
- Weakness
- Abdominal pain and swelling
- Chest pain
- Skin color changes
- Melena
- Hematuria
- Hematemesis
- Abnormal uterine bleeding
Assessment:
1. Monitor blood pressure and heart rate. Note orthostatic hypotension.
During a severe bleeding episode, the body compensates initially by increasing heart rate to maintain cardiac output. Orthostatic hypotension is the sudden drop of systolic BP of 20 mmHg and diastolic BP of 10 mmHg when getting up from lying or sitting down. It suggests decreased circulating fluid volume.
2. Assess the skin and mucous membrane for petechiae, bruising, hematoma, and active bleeding.
Patients with thrombocytopenia or other conditions that disrupt clotting factor activity may exhibit clinical manifestations of bleeding into tissues.
3. Review laboratory findings for coagulation status.
Dysregulation of clotting factors impairs the body’s ability to form clots in the blood to stop bleeding. Laboratory values will provide information on bleeding risk and coagulation status.
Interventions:
1. Be prepared to administer hemostatic agents if prescribed.
There are a variety of mechanisms of action of hemostatic medications, but overall, they are given to control bleeding. Other medications, such as proton pump inhibitors, may reduce the underlying cause of the bleeding.
2. Instruct the patient and family about the signs and symptoms of potential bleeding episodes.
Early evaluation would facilitate prompt notification of healthcare providers to render treatment.
3. Teach about any anticoagulant medications prescribed.
Medication teaching includes the drug name, purpose, administration instructions (e.g., with or without food), necessary lab tests, and any side effects to be aware of. Provision of such information using clear communication principles may facilitate appropriate adherence to the therapeutic regimen by enhancing baseline knowledge.
4. For bleeding associated with excessive anticoagulant use, administer appropriate antidotes as prescribed.
There are reversal agents for most anticoagulants. Protamine sulfate reverses heparin toxicity and vitamin K reverses warfarin.
5. Administer blood products as prescribed.
Depending on the underlying etiology of the abnormality in clotting, blood products may be used to treat it. For instance, plasma transfusions may be used to reintroduce clotting factors into the blood.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
- Gulanick, Meg, and Judith L. Myers. Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier/Mosby, 2014.
- Herdman, T. Heather, and Shigemi Kamitsuru. Nursing Diagnoses: Definitions and Classification 2018-2020. Thieme, 2018.
