This guide is about risk for bleeding, risk for bleeding nursing diagnosis, and risk for bleeding nursing care plans. It can be utilized in the creation of risk for bleeding nursing care plans for educational purposes only.
Risk for bleeding
What is risk for bleeding?
Risk for Bleeding is a NANDA nursing diagnosis that can be used for the care of patients with increased chances of bleeding, such as those diagnosed with reduced platelets, problems with clotting factors, or those in situations where the patient experiences a traumatic injury or an invasive procedure such as surgery.
Any condition that causes disturbance to the integrity of the circulatory system may result to increased risk for bleeding.
Causes of Bleeding
What causes bleeding?
- Decreased quantity or quality of circulating platelets in the blood (such as in thrombocytopenia or trauma)
- Interference in the genetic expression of clotting factors (such as hemophilia)
- Increased number of platelets (such as in immune thrombocytopenic purpura or ITP)
- Reduction of the bone marrow’s capacity to produce platelets (such as in blood cancers)
- Liver impairment or other conditions where there is a decreased rate in the synthesis of clotting factors
Risk Factors of Bleeding
What is risk for bleeding related to?
- Trauma or injury
- Invasive diagnostic procedures
- Gastrointestinal disorders such as peptic ulcer disease (PUD) and inflammatory bowel disease (IBD)
- Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), systemic anti-cancer therapy agents (SACT) may cause bone marrow suppression
- Some herbal remedies that can affect clotting factors, such as ginseng and gingko biloba
Risk for Bleeding Nursing Diagnosis
What are the nursing diagnosis for bleeding?
|Assess the patient’s past medical history and note diseases that might pose a higher risk for bleeding. The following conditions, among others, may contribute to a higher risk of bleeding.
Any condition or organ that affects blood formation or platelet formation and alters coagulation abilities might contribute to a higher risk of bleeding. Identifying potential risk allows for the early implementation of preventative measures.
|Perform a fall risk assessment on admission using a fall risk assessment tool. Consider
History of falls
Fall risk assessment tools help identify the level of measures that need to be implemented to keep the patient safe.
|Complete a medication reconciliation and note medications that can contribute to the risk for bleeding.
Blood thinners (e.g., Warfarin, Heparin)
Aspirin and NSAIDs inhibit inflammatory processes such as platelet aggregation, Warfarin interferes with the formation of vitamin K-dependent clotting factors, and chemotherapy drugs can affect the bone marrow, where platelets are produced. SSRIs prevent platelet aggregation. Heparin interferes with the clotting cascade preventing the conversion of fibrinogen to fibrin.
|Monitor vital signs frequently.
Changes in blood pressure and heart rate could be indications for internal bleeding. An increase in heart rate and decreased blood pressure may be a sign of blood loss in the vascular system. Blood loss reduces vascular volume leading to low blood pressure, whereas an increased heart rate is a compensatory attempt of the body to pump blood faster through the system to make up for lost volume.
|Check orthostatic vital signs per order.
Orthostasis can occur from low vascular volume. A patient is positive for orthostatic hypotension if the systolic blood pressure drops by 20mmHg and the diastolic blood pressure by 10mmHg when changing from lying down to sitting up or standing up. Expect the patient to feel dizziness or lightheadedness.
|Monitor the patient for signs of increased bleeding or hemorrhage.
Bloody urine (hematuria)
Any of these signs may indicate bleeding. Further investigation is warranted. Note frequency and amount.
|Monitor coagulation studies frequently.
Partial Thromboplastin Time (PTT)
Increased values may indicate an increased risk for bleeding. These values also aid in adjustments of medication dosages such as heparin shots, infusions, and Warfarin.
|Monitor hematocrit and hemoglobin regularly.
Patients might be asymptomatic despite losing blood. These values allow early identification of blood loss.
|Obtain occult stool and urine samples as ordered.
Occult tests detect blood that is not visible with the naked eye.
Risk for Bleeding Nursing Interventions
What are the nursing interventions for bleeding?
|Anticipate the administration of blood products and volume expanders if indicated and ordered.
Blood administration and other products and fluids such as saline or albumin help restore circulating volume in the vascular system. Products to be given may include red blood cells, fresh frozen plasma, platelets, and cryoprecipitate.
|Keep antidotes available on the unit.
Protamine sulfate is the antidote for heparin. Vitamin K reverses the effects of Warfarin.
|If bleeding occurs, hold pressure on the site until the bleeding is controlled.
Pressure devices and dressings may be used if indicated.
|Ensure adequate staffing to monitor patients that are at higher risk for bleeding adequately.
Sufficient personnel allows for closer and more frequent observation and promotes safety.
|Obtain baseline laboratory studies.
This information is essential for the initiation of anticoagulant therapy.
|Check laboratory tests before administration.
Lab values such as INR or platelet count can change quickly. Medication that was appropriate one day might not be suitable the next day. Trending these lab values ensures proper monitoring and dosing.
|Collaborate with the dietitian to adjust portions of certain foods to avoid counteracting anticoagulation therapy.
Foods such as spinach, kale, collard greens, and brussels sprouts may interfere with warfarin therapy because these foods contain vitamin K.
|Perform frequent neuro checks on the patient.
Blood loss reduces the number of oxygen-carrying red blood cells leading to decreased oxygenation of organs, especially the brain. These changes might lead to a reduced neurological function.
Risk for Bleeding Patient Teachings
How can you reduce the risk of bleeding?
|Teach the patient to use a soft-bristled toothbrush and avoid floss and toothpicks.
Soft toothbrushes decrease the risk of irritating the gum tissue and cause bleeding. Flossing and using toothpicks might cause trauma to gums and cause bleeding.
|Encourage male patients to use an electric shaver or clippers.
Electric shavers and clippers are less likely to cause trauma to tissues.
|Teach patients to avoid blowing their nose forcefully, sneezing, coughing, or straining with bowel movements.
These activities can cause trauma to mucosal linings.
|Teach the patient and family to hold pressure for at least 5 to 10 minutes if bleeding occurs.
The patient and family need to know what to do when the patient is bleeding. Knowledge about which actions to take in critical situations may reduce the number of hospitalizations.
|Advise the patient to avoid situations that could cause injury or bleeding, such as contact sports or dealing with sharp objects such as knives and scissors.
The patient needs to learn to recognize situations that could cause tissue trauma and bleeding.
|Emphasize the importance of taking medications at the same time each day.
Taking medications at the same time ensures to maintain a certain level of the drug in the body.
|Teach about dietary considerations.
It is important to keep the amount of green leafy vegetables containing vitamin K consistent. Increasing or decreasing the amount of these foods might need a dosage adjustment.
|Encourage the patient to increase fluid intake if not contraindicated and eat a diet high in fiber to reduce instances of constipation.
Hard and dry feces may cause trauma to mucous membranes of the colon and rectum.
|Teach the patient to monitor stools for color and consistency.
Black tarry stools might indicate an upper gi bleed, whereas bright red color might mean a lower gi bleed.
|Teach the patient to read medication labels when taking over the counter medicine. Avoid taking NSAIDs, aspirin, and other salicylates while taking blood thinners unless specifically ordered by the physician.
Taking these medications in addition to prescribed blood thinners and antiplatelet medicine may increase the risk of bleeding.
|Remind the patient to inspect the skin and mucous membranes regularly for bleeding.
By monitoring the skin frequently, early detection of bleeding and possible coagulation abnormalities is possible.
|Teach the patient and family about the use of herbals.
Some herbals and supplements might increase the risk of bleeding. Examples are ginger, ginkgo biloba, chamomile, and feverfew. Some of these herbals possess antiplatelet properties, and some increase anticoagulation.
|Advise the patient to keep follow-up appointments to monitor the effects of anticoagulant therapy.
Regular lab tests promote safety and allow the physician to make adjustments if necessary.
|Instruct the patient to let his or her dentist know about anticoagulant therapy before any procedures.
Dental work may involve invasive procedures that can cause trauma and bleeding.
|Have the patient wear an ID bracelet stating anticoagulant therapy.
This information can be taken into consideration during an emergency in which the patient might be unresponsive.
|Teach about signs and symptoms that require medical attention.
Knowing the signs of bleeding and hematoma formation allows for quick intervention and promotes safety.
|Provide verbal and written material about the education points of anticoagulant therapy.
Written material allows the patient and family to refer back and review information at any time. Both forms of education can reinforce learned material and help the patient, and family members better understand health information.
Risk for Bleeding Nursing Care Plans.
What are the nursing care plans for bleeding?
Nursing Care Plan 1
Nursing Diagnosis: Risk for Bleeding related to invasive surgical procedure
Desired Outcome: To prevent any bleeding episode during or after the surgical procedure.
|Assess the patient’s vital signs and perform a focused physical assessment, looking for any signs of bleeding.||Any invasive procedure such as surgery can put the patient at risk for bleeding. Early signs of bleeding include gum bleeding, epistaxis, and unexplained bruises. Low blood pressure, low temperature, and dizziness may result from excessive bleeding.|
|Before the operation, obtain blood samples (Labs) to check platelet counts as well as coagulation levels (INR, PT, and PTT).||To measure the risk of bleeding by having a baseline of the platelet counts and coagulation levels of the patient.|
|Advise the patient to stop the use of non-steroidal anti-inflammatory drugs (NSAIDs), anticoagulants, and certain herbal remedies prior to surgery, as indicated by the physician.||NSAIDs and anticoagulants can increase the risk for bleeding. Some herbal remedies can affect clotting factors, such as ginseng and gingko biloba.|
|Obtain type and cross match of patients blood. Anticipate the need for the patient to have whole blood replacements.||To prepare for any need to perform blood transfusion as prescribed. If the blood loss is too much and immediate correction is warranted, whole blood transfusion is administered.|
|Perform the blood transfusion if indicated.||Blood transfusion may be required if there is too much blood loss.|
|Post-surgery, assess and monitor the patient’s surgical wound site for any signs of unexpected bleeding.||To treat any unexpected bleeding as early as possible.|
Nursing Care Plan 2
Peptic Ulcer Disease
Nursing Diagnosis: Risk for Bleeding related to open sores in the gastrointestinal lining secondary to peptic ulcer disease
Desired Outcome: To prevent any gastrointestinal bleeding episode.
|Assess vital signs, particularly blood pressures.||Hypovolemia due to GI bleeding may lower blood pressure levels and put the patient at risk for hypotensive episodes that lead to shock.|
|Collect urine and stool samples for occult blood testing.||Patients at risk for bleeding such as those diagnosed with PUD may not show apparent signs and symptoms of bleeding, thus checking for the presence of blood in the stool or urine is an important nursing intervention.|
|Start intravenous therapy as prescribed. Electrolytes may need to be replaced intravenously. Encourage oral fluid intake of at least 1000 mL per day if not contraindicated.||To replenish the fluids and electrolytes lost from vomiting or other gastric losses, and to promote better blood circulation around the body.|
|Anticipate that the physician my put the patient in an “NPO” or nothing per Orem/ nothing by mouth status as ordered.||To allow the stomach lining to heal, and to prepare the patient for diagnostic procedure (endoscopy).|
|Prepare the patient for endoscopy.||The endoscopist can diagnose and treat bleeding peptic ulcers while the patient undergoes endoscopy.|
|Perform the blood transfusion if indicated.||To increase the hemoglobin level and treat anemia and hypovolemia related to bleeding ulcers.|
|Administer proton-pump inhibitors (PPIs) as prescribed.||To facilitate the treatment of bleeding peptic ulcers or to prevent the formation of more ulcers.|
|Advise the patient to stop or avoid the use of non-steroidal anti-inflammatory drugs (NSAIDs).||NSAIDs are some of the most common causes of peptic ulcer disease and can increase the risk for bleeding.|
Nursing Care Plan 3
Nursing Diagnosis: Risk for Bleeding related to decreased clotting factors in the circulating blood secondary to hemophilia
Desired Outcome: To prevent any bleeding episode by using appropriate preventive/ prophylactic measures.
|Assess the patient’s vital signs and perform a focused physical assessment, looking for any signs of bleeding.||Problems in clotting factors in medical conditions such as hemophilia put the patient at risk for bleeding. Early signs of bleeding include gum bleeding, epistaxis, and unexplained bruises. Low blood pressure, low temperature, and dizziness may result from excessive bleeding.|
|Obtain blood samples to monitor coagulation essays for factors VIII and IX.||Factor replacement therapy can be subtherapeutic in decreased levels of factors VIII and IX.|
|Obtain Group and Save blood samples from the patient. Anticipate the need for the patient to have whole blood replacements.||To prepare for any need to perform blood transfusion as prescribed. If the blood loss is too much and immediate correction is warranted, whole blood transfusion is administered.|
|Prepare the patient for clotting factor replacement therapy. Anticipate the need for administering a clotting factor product as prophylaxis prior to surgical procedures, invasive diagnostic tests, or dental work.||Clotting factor concentrates can be injected to the patient with hemophilia to replace the missing blood factor/s. The two types of clotting factor products include plasma-derived concentrates and recombinant factor concentrates. Cryoprecipitate and monoclonal antibodies are other options in treating hemophilia and reducing the risk for bleeding.|
|Administer anti-fibrinolytics as a second-line treatment.||Anti-fibrinolytics are drugs that stop plasmin activity, helping the clot to stay in place. However, they cannot replace the action or benefit of a clotting factor replacement product. These anti-fibrinolytics are usually given as prophylaxis for female hemophilia patients with heavy menstrual bleeding, or for those who are schedule for dental work.|
|Advise patient to use a soft-bristled toothbrush as well as a non-abrasive toothpaste.||To reduce the risk of trauma to the oral mucosa and gums, which may lead to a bleeding episode.|
|Educate the patient about avoiding tampons, vaginal douche, enemas, rectal suppositories, and other invasive medications or devices. Also, advise him/her to avoid forceful nose blowing and straining with bowel movement.||To reduce the risk of trauma to mucous membranes of the body, which may lead to a bleeding episode.|
Nursing Care Plan 4
Immune Thrombocytopenia Purpura (ITP)
Nursing Diagnosis: Risk for Bleeding related to low platelet count secondary to Immune Thrombocytopenia Purpura (ITP)
Desired Outcome: To prevent any bleeding episode and improve platelet count.
|Assess the patient’s vital signs and perform a focused physical assessment, looking for any signs of bleeding.||Low platelet counts in medical conditions such as ITP put the patient at risk for bleeding. Early signs of bleeding include gum bleeding, epistaxis, and unexplained bruises. Low blood pressure, low temperature, and dizziness may result from excessive bleeding.|
|Obtain blood samples and monitor platelet counts as well as coagulation levels (INR, PT, and PTT).||To measure the risk of bleeding by knowing the platelet counts and coagulation levels of the patient.
To check for the need for platelet transfusion.
|Administer blood or platelet transfusion as prescribed.||If the platelet level is too low and immediate correction is warranted, platelet or whole blood transfusion is administered.|
|Prepare the patient for splenectomy as indicated.||Splenomegaly with bone marrow suppression may be the cause of ITP. Splenectomy or the removal of spleen was the recommended treatment for ITP and steroid-refractory thrombocytopenia; however, the advent of new treatments such as thrombopoietin receptor antagonists renders splenectomy as one of the last resorts for the treatment of ITP.|
|Advise patient to use a soft-bristled toothbrush as well as a non-abrasive toothpaste.||To reduce the risk of trauma to the oral mucosa and gums, which may lead to a bleeding episode.|
Nursing Care Plan 5
Patients on Anti-coagulant Therapy
Nursing Diagnosis: Risk for Bleeding related to anticoagulant therapy
Desired Outcome: To prevent any bleeding episode while the patient is on anticoagulant therapy.
|Anticoagulants put the patient at risk for bleeding as they are prescribed to reduce blood clots. Early signs of bleeding include gum bleeding, epistaxis, and unexplained bruises. Low blood pressure, low temperature, and dizziness may result from excessive bleeding.|
|Obtain blood samples and monitor platelet counts as well as coagulation levels (INR, PT, and PTT).||To ensure that the anticoagulant dosing is in line with the target therapeutic range, thus reducing the risk of bleeding. Increased INR, PT and PTT in a patient on anticoagulant therapy means an increased risk for bleeding. This calls for an immediate review of the right dose for the patient.|
|Administer the anticoagulant as prescribed.||There are different anticoagulants in different forms. The most common ones are IV heparin, subcutaneous low-molecular weight heparin (LMWH), and oral warfarin.|
|Recommend switching from IV anticoagulant to subcutaneous or oral anticoagulant to the doctor when the therapeutic range has been reached.||To facilitate safe transition of anticoagulation therapy from clinical management to patient self-management before discharge.|
|Collect urine and stool samples for occult blood testing.||Patients on anticoagulant therapy may not show apparent signs and symptoms of bleeding, thus checking for the presence of blood in the stool or urine is an important nursing intervention.|
|In the event of a bleeding episode due to excessive use of anticoagulants, administer the appropriate antidote as prescribed.||Vitamin K is currently used for warfarin overdose. Protamine sulfate is currently used for heparin overdose.|
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