Risk for Bleeding

Risk for bleeding is a Nanda nursing diagnosis classified in the latest update of Nanda nursing diagnosis list 2015-2017 under domain 11: safety/protection, class 2: physical injury. Its nanda nursing diagnosis code is 00206.

Definition:

At risk for a decrease in blood volume that may compromise health.

Related factors :

• Trauma
• Treatment regimen: drugs inhibiting platelet function such as anticoagulants (Heparin), NSAIDs, Antibiotics, Dextran.
• Abnormal Liver function (hepatitis, cirrhosis).
• History of falls: Age greater than 70 years.
• Disseminated intravascular coagulopathy
• Gastrointestinal conditions (varices, polyps ,ulcer)
• Postpartum complications (retained placenta, uterine atony)
• Pregnancy complication (e.g., premature rupture of membranes, placenta previa/ abruption, multiple gestation)
• Inherent coagulopathy (e.g., thrombocytopenia)
• Aneurysm
• Circumcision
• Deficient knowledge

Defining Characteristics:

Not applicable for a risk diagnosis, presence of a defining characteristic defines an actual diagnosis.

Expected Outcomes:

• Client takes measures to prevent bleeding and recognises signs of bleeding that need to be reported immediately to a health care professional
• Absence bleeding as evidenced by normal blood pressure, stable hematocrit and haemoglobin levels and desired ranges for coagulation profiles.

NOC Outcomes:

• Blood Coagulation
• Knowledge: Disease process
• Knowledge: Medication
• Risk Control

NIC Interventions:

• Bleeding Precautions
• Bleeding Reduction
• Teaching: Disease Process
• Teaching: Prescribed Medication

Nursing Interventions and rationale:

1. Obtain complete health history for bleeding, some individuals know whereas others do not.

Rationale: Assessment findings may indicate need for protective measures.

2.  Assess and monitor vital signs of patient.

Rationale: Tachycardia and orthostatic changes accompany bleeding.

3.  Monitor platelet count and coagulation test results.

Rationale: Spontaneous bleeding may occur at platelet count <50,000/mm3 and abnormal coagulation test result.

4.  Avoid intravenous, intramuscular, subcutaneous injections and rectal procedures.

Rationale: These procedures can stimulate bleeding.

5.  Observe for skin necrosis, changes in blue or purple mottling of feet that blanches with pressure or fades when legs are elevated.

Rationale: Patient on anticoagulant therapy remains at risk of developing emboli.

6.  Awareness to patient about effects of drugs like heparin and warfarin.

Rationale: This enables the patient to avoid bleeding-risk situations.

7.  Maintain safe and comfortable environment for patient to promote a lifestyle that focuses on health promotion.

Rationale: To prevent depression and injury.

8.  Provide psychological and emotional support to patient.

Rationale: This helps in patient’s assurance and calming.

9.  Be active in decision making about the treatment of the patient at risk for bleeding.

Rationale: Active participation encourages fuller understanding of the rationale and compliance with the treatment.

10. Keep in touch with blood transfusion centre.

Rationale: To assure availability of blood when needed.