Introduction to Nursing Care Plan for Risk for Bleeding
Risk for Bleeding: Risk for Bleeding is defined as an increased susceptibility to bleeding, either due to lack of clotting factors or other causes such as trauma or the use of medications that inhibit platelet aggregation.
The assessment of a patient’s risk for bleeding may include a medical history, physical examination, blood tests, and imaging studies. Medical history should include questions about medications, family history, lifestyle, and past medical problems. The physical examination focuses on identifying areas where bleeding can occur.
- Inspect the skin for petechiae (small red or purple spots caused by minor bleeding under the skin)
- Inspect the mouth and throat for bleeding gums or oral lesions
- Palpate (examine by feeling) the abdomen to feel for enlarged organs or bleeding vessels
- Auscultate (listen to) the lungs and heart for any unusual sounds that may indicate bleeding
Blood tests are used to measure the levels of clotting factors and platelets in the blood. Imaging studies such as magnetic resonance imaging (MRI) or computed tomography (CT) scans may be used to look for evidence of bleeding in the brain or other areas of the body.
Based on the assessment, the nursing diagnosis of risk for bleeding includes the following possible diagnoses:
- Ineffective tissue perfusion related to decreased circulating blood volume
- Impaired skin integrity related to decreased clotting factors
- Risk for activity intolerance related to decreased oxygen carrying capacity of the blood
- Risk for infection related to increased clotting time
The desired outcomes of a nursing care plan for risk for bleeding are:
- Reduce the risk of bleeding
- Preserve and maintain skin integrity
- Maintain adequate tissue oxygenation
- Prevent infection
Interventions for a nursing care plan for risk for bleeding include:
- Provide wound care for any existing wounds
- Encourage fluids and a diet high in acidophilic foods
- Assess the site of any new bleeding and initiate treatment as needed
- Perform platelet transfusions or other treatments as ordered
- Monitor vital signs and level of consciousness
Rationales for interventions in a nursing care plan for risk for bleeding include:
- Wound care helps to reduce the risk of infection and further tissue damage from bleeds.
- Acidophilic foods are rich in Vitamin K and other clotting factors.
- Early evaluation and treatment of any new bleeding can help prevent further tissue damage or loss of life.
- Platelet transfusions can help to reduce the risk of bleeding.
- Vital signs and level of consciousness are monitored to detect changes in blood pressure or decreased level of consciousness that may indicate internal bleeding.
Successful evaluation of the nursing care plan for risk for bleeding should result in a:
- Reduced risk of bleeding
- Preserved and maintained skin integrity
- Adequate tissue oxygenation
- Decreased risk of infection
Risk for bleeding is a serious condition that requires close monitoring and early intervention. With proper management and assessment, a nursing care plan for risk for bleeding can help to reduce the risk of complications and maintain tissue integrity.
Frequently Asked Questions
- What is Risk for Bleeding? Risk for bleeding is an increased susceptibility to bleeding, either due to lack of clotting factors or other causes such as trauma or the use of medications that inhibit platelet aggregation.
- What is the purpose of a Nursing Care Plan for Risk for Bleeding? The purpose of a nursing care plan for risk for bleeding is to reduce the risk of bleedings, preserve and maintain skin integrity, maintain adequate tissue oxygenation and prevent infection.
- What kind of interventions should be used? Interventions for a nursing care plan for risk for bleeding include providing wound care, encouraging fluids and a diet high in acidophilic foods, assessing the site of any new bleeding and initiating treatment as needed, performing platelet transfusions or other treatments as ordered, and monitoring vital signs and level of consciousness.
- What are the expected outcomes? The desired outcomes of a nursing care plan for risk for bleeding are reducing the risk of bleeding, preserving and maintaining skin integrity, maintaining adequate tissue oxygenation, and preventing infection.
- What is the evaluation process? Successful evaluation of the nursing care plan for risk for bleeding should result in a reduced risk of bleeding, preserved and maintained skin integrity, adequate tissue oxygenation, and decreased risk of infection.