Last updated on February 21st, 2023 at 10:30 am
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
- 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
- Trauma or injury
- Surgery
- 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
- Anticoagulants
- Some herbal remedies that can affect clotting factors, such as ginseng and gingko biloba
Risk for Bleeding Nursing Diagnosis
Risk for Bleeding Nursing Care Plan 1
Surgery
Nursing Diagnosis: Risk for Bleeding related to invasive surgical procedure
Desired Outcome: To prevent any bleeding episode during or after the surgical procedure.
| Risk for Bleeding Nursing Interventions | Rationales |
| 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. |
Risk for Bleeding Nursing Care Plan 2
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.
| Risk for Bleeding Nursing Interventions | Rationales |
| 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. |
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.
| Risk for Bleeding Nursing Interventions | Rationales |
| 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. |
Risk for Bleeding 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.
| Risk for Bleeding Nursing Interventions | Rationales |
| 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. |
Risk for Bleeding 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.
| Risk for Bleeding Nursing Interventions | Rationales |
| Assess the patient’s vital signs and perform a focused physical assessment, looking for any signs of bleeding. | 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. |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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