Nursing Diagnosis and management of bleeding disorders.
Potential bleeding* and injury secondary to thrombocytopenia/altered coagulation due to:
• Malignant invasion in bone marrow
• Bone marrow suppression resulting from chemotherapy (particularly alkylators, antitumor antibiotics, antimetabolites) and radiation therapy
• Disseminated intravascular coagulation (DIC)
• Altered coagulation
Assess the following areas thoroughly every shift or visit (with spot checks throughout the shift if patient is hospitalized), and notify physician if there is new onset of the following and/or worsening of status:
• Integument: Petechiae (usually located on trunk, thighs), ecchymoses or hematomas, conjunctival hemorrhages, bleeding gums, bleeding at puncture sites (venipuncture, lumbar puncture, bone marrow)
• Cardiovascular: Hypotension, tachycardia, complaints of dizziness, epistaxis
• Pulmonary: Respiratory distress, tachypnea
• Gastrointestinal: Hemoptysis, abdominal distention, rectal bleeding
• Genitourinary: Vaginal or urethral bleeding
• Neurologic: Headache, blurred vision, mental status changes
• Monitor complete blood count (CBC), platelets daily (at least); coagulation panel.
• Notify physician if platelet count is <10,000/mm3 or if count has changed significantly from previous count (including coagulation), or whenever patient becomes symptomatic.
• Ensure patient’s blood was human leukocyte antigen (HLA) typed before transfusions or chemotherapy begins if admitted for induction therapy (eg, for acute leukemia).
• Obtain 1-hour posttransfusion platelet count if warranted.
• Test all urine, emesis, stools for occult blood.
• Avoid aspirin and aspirin-containing medications or other medications known to inhibit platelet function, if possible.
• Do not give intramuscular injections.
• Do not insert indwelling catheters.
• Take no rectal temperatures; do not give suppositories, enemas.
• Use stool softeners, oral laxatives to prevent constipation.
• Use smallest possible needles when performing venipuncture.
• Apply pressure to venipuncture sites for 5 min or until bleeding has stopped.
• Permit no flossing of teeth and no commercial mouthwashes.
• Use only soft-bristled toothbrush for mouth care.
• Use only toothettes for mouth care if platelet count is <10,000/mm3, or if gums bleed.
• Lubricate lips with water-soluble lubricant every 2 hr while awake.
• Avoid suctioning if at all possible; if unavoidable, use only gentle suctioning.
• Discourage vigorous coughing or blowing of the nose.
• Use only electric razor for shaving.
• Pad side rails as needed.
• Prevent falls by ambulating with patient as necessary.
• Apply direct pressure.
• For epistaxis, position patient in high Fowler’s position; apply ice pack to back of neck and direct pressure to nose.
• Notify physician for prolonged bleeding (eg, unable to stop within 10 min).
• Administer platelets, fresh frozen plasma, packed red blood cells, as prescribed.
Evaluation and Expected Patient Outcomes
• Patient demonstrates an absence of bleeding as evidenced by absence of spontaneous petechiae, ecchymoses, epistaxis, hemoptysis, bleeding gums, conjunctival hemorrhage, vaginal bleeding, hematuria, guaiac positive stool, blurred vision, orthostatic hypotension, and prolonged bleeding from puncture sites.
• Patient demonstrates an absence of bleeding as evidenced by the presence of vital signs within normal limits and intact neurologic status.