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.
At risk for a decrease in blood volume that may compromise health.
Related factors :
- 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)
- Deficient knowledge
- 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.
- Blood Coagulation
- Knowledge: Disease process
- Knowledge: Medication
- Risk Control
- 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.