Interview/screen each individual for risk factors for bleeding; some individuals know their risks for bleeding, others do not, and clinical tests and evaluation by expert clinicians allow for preventive or corrective intervention measures.- Anticipate conditions and episodes of care that may precipitate bleeding. The clinicians in high-risk areas (trauma, emergency departments, ante/intra/postpartum, surgery) must be prepared and be aware of patient conditions and changes that could precede a bleeding event.
Monitor physiologic responses (vital signs, O2 level, LOC [behavior]) for values that remain in expected or normal ranges; early bleeding compensatory mechanisms alter respirations, pulse, and blood pressure, and subtle changes can be detected by a perceptive clinician.- Monitor for frank bleeding and for occult bleeding in urine and feces through assessment of wounds, dressings, and eliminated body fluids either by visual inspection or with the aid of easy chemical testing (guaiac hemoccult).
- Correlate interview 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 according to evidence-based protocols for the in-hospital patient who is at risk for bleeding until it is assured the patient is no longer at risk for bleeding.
- Obtain clinical laboratory tests (hemoglobin, hematocrit, CBC, thrombin time [TT], prothrombin time [PT], activated partial thromboplastin time [APTT], others) and point-of-care tests (guaiac, urine dip test, gastroccult) to monitor for trend changes in values that would indicate a risk for bleeding or that a bleeding episode is in process.
- Examine surgical and wound dressings; drainage tubes and collection canisters to measure the amount of bleeding and seepage the patient experiences and compare this with the expected blood loss for similar conditions.
Teach about intended effects of medications (heparin, enoxaparin, warfarin, clopidogrel, aspirin) that increase the risk for bleeding or prolong clotting. This enables the patient to avoid situations that could cause bleeding (shaving, sports, vigorous tooth brushing) and to observe self for bleeding. - Teach about unintended or adverse effects of medications (corticosteroids, aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs]) that increase the risk for bleeding or prolong clotting. This enables the patient to avoid situations that could cause bleeding (shaving, sports, vigorous tooth brushing) and to observe self for bleeding.
- Teach patient gentle alternatives in activities of daily living (ADLs) to avoid trivial trauma that may cause injury and bleeding.
- Teach patient about inherent conditions (thrombocytopenia, hemophilia) and devise an approach to lifestyle that protects patient from injury and yet is satisfying and has a positive quality of life.
- Teach patient patterns of risk management and promotion of a lifestyle that focuses on health promotion and injury avoidance because this will diminish the possibility of injury. Having the knowledge to participate safely will increase independence and enhance self-esteem.
- Provide care that protects the individual with a risk for bleeding from injury to prevent bleeding.
- Implement evidence-based interventions that reverse or remove the risk for bleeding or the bleeding condition. These interventions will prevent patient from bleeding or will stabilize patient's physiologic condition and assist in recovery.
- Provide emotional support to patient who is experiencing an episode of bleeding and also physiologic compensatory responses such as anxiety, fear, and a sense of dread. This support provides assurance and is calming.
- Support patient in participating in decisions about the treatment regimen that places the patient at risk for bleeding. This active participation encourages greater understanding of the rationale and compliance by the patient with the treatment regimen (for medications, see earlier).
Refer patient at risk for bleeding secondary to treatment goals (i.e., warfarin, international normalized ratio [INR] level) to a case manager or advanced practice nurse for clinical monitoring and reinforcement of teaching and lifestyle adjustments.- Manage and monitor the recovery progress of patient who experienced a bleeding episode because patient may be weak and at safety risk for falls or injury.
- Refer to a case manager the patient with inherent conditions that require long-term monitoring and management so that patient can maintain independence safely.
Suggested NIC Interventions
Hemodynamic Regulation; Intravenous (IV) Therapy; Circulatory Care; Hypovolemic Management; Vital Signs Monitoring; Fluid Management; Laboratory Data Interpretation; Shock Management |