Risk for bleeding is a significant concern in healthcare, defined as the potential for a decrease in blood volume that could compromise health. Effective nursing care hinges on the ability to assess, prevent, and manage bleeding risks. This article provides a comprehensive guide to understanding and addressing the nursing diagnosis of risk for bleeding, offering essential insights for healthcare professionals.
It’s important to note that the nursing diagnosis “Risk for Bleeding” has been updated to “Risk for Excessive Bleeding” by NANDA International. While the updated terminology is gaining traction, this guide will continue to use “Risk for Bleeding” to ensure clarity and familiarity, reflecting common usage in clinical practice.
Risk Factors for Bleeding
Identifying individual risk factors is the cornerstone of effective bleeding prevention. These factors can be broadly categorized and are crucial for tailoring interventions to each patient’s specific needs.
Common Risk Factors:
- Medications: Anticoagulants (like warfarin, heparin, aspirin), NSAIDs (ibuprofen, naproxen), antiplatelet drugs (clopidogrel), thrombolytics, and certain chemotherapy agents significantly impair hemostasis, increasing bleeding risk.
- Medical Conditions:
- Coagulation Disorders: Hemophilia, von Willebrand disease, and thrombocytopenia directly affect the body’s clotting ability.
- Liver Disease: Impaired liver function reduces the production of clotting factors.
- Gastrointestinal Conditions: Peptic ulcers, gastritis, esophageal varices, and inflammatory bowel disease can lead to gastrointestinal bleeding.
- Kidney Disease: Renal failure can affect platelet function and coagulation.
- Cancer: Certain cancers, especially leukemia and metastatic disease, and their treatments can increase bleeding risk.
- Aneurysm: Weakened blood vessel walls are prone to rupture and bleeding.
- Disseminated Intravascular Coagulation (DIC): A life-threatening condition involving abnormal blood clotting throughout the body, paradoxically leading to both clotting and bleeding.
- Procedures and Treatments:
- Surgery and Trauma: Any surgical procedure or traumatic injury carries a risk of blood vessel damage.
- Invasive Procedures: Central line insertion, biopsies, and lumbar punctures can cause bleeding.
- Chemotherapy and Radiation Therapy: These treatments can suppress bone marrow function, leading to thrombocytopenia and increased bleeding risk.
- Dialysis: Hemodialysis involves anticoagulation and can increase bleeding risk.
- Patient-Specific Factors:
- Age: Older adults are more susceptible to bleeding due to age-related physiological changes.
- History of Bleeding: Patients with a previous history of bleeding events are at higher risk.
- Nutritional Deficiencies: Vitamin K deficiency impairs clotting factor synthesis.
- Alcohol Abuse: Chronic alcohol use can lead to liver damage and coagulopathy.
Note: Risk diagnoses are based on potential problems, not existing signs and symptoms. Interventions are preventative.
Expected Outcomes for Bleeding Risk
Care goals for patients at risk of bleeding are centered on prevention and patient education. Measurable outcomes help evaluate the effectiveness of the care plan.
Expected Outcomes:
- Absence of Bleeding: The patient will not experience bleeding, as evidenced by:
- Hemoglobin and hematocrit levels within normal limits.
- Prothrombin time (PT) and International Normalized Ratio (INR) within desired ranges.
- Stable blood pressure and heart rate within normal parameters.
- Absence of overt signs of bleeding (e.g., bruising, hematoma, bleeding gums, melena, hematuria, hematemesis).
- Understanding Bleeding Precautions: The patient will verbalize understanding of specific measures to prevent bleeding in their daily activities and healthcare interactions.
- Recognition of Bleeding Signs: The patient will verbalize recognition of signs and symptoms of bleeding that require prompt reporting to a healthcare provider.
Nursing Assessment for Bleeding Risk
A thorough nursing assessment is crucial for identifying patients at risk for bleeding and guiding appropriate interventions. This assessment includes both subjective and objective data collection.
1. Medical History Review: Assess the patient’s medical history for pre-existing conditions that elevate bleeding risk. This includes documented bleeding disorders, liver disease, gastrointestinal issues, kidney disease, cancer, and any past bleeding episodes. Identifying these historical factors allows for proactive preventative strategies.
2. Medication Reconciliation: Carefully review the patient’s current medication list, paying close attention to drugs that can compromise hemostasis. This includes anticoagulants, antiplatelet agents, NSAIDs, and chemotherapy drugs. Document the dosage, frequency, and route of administration for all identified medications. Consider potential drug interactions that might further increase bleeding risk.
3. Vital Signs Monitoring: Regularly monitor vital signs, particularly blood pressure and heart rate. Pay attention to trends and report any significant deviations from baseline. Tachycardia (increased heart rate) and hypotension (low blood pressure) are often early indicators of blood loss and should prompt further investigation.
4. Orthostatic Hypotension Assessment: Assess for orthostatic hypotension by measuring blood pressure and heart rate in lying, sitting, and standing positions. A significant drop in blood pressure (systolic decrease of 20 mmHg or diastolic decrease of 10 mmHg) or an increase in heart rate when changing position can indicate reduced blood volume, potentially due to bleeding. Orthostatic hypotension also increases the risk of falls, which can lead to bleeding injuries.
5. Physical Examination: Conduct a systematic physical examination to identify any signs of bleeding.
- Skin and Mucous Membranes: Inspect for petechiae (small, pinpoint hemorrhages), ecchymosis (bruising), hematomas (localized collections of blood), and active bleeding from any site (e.g., gums, nose, wounds).
- Gastrointestinal System: Assess for abdominal distention, tenderness, or guarding, which could suggest internal bleeding. Check for melena (black, tarry stools) or hematemesis (vomiting blood).
- Genitourinary System: Observe urine for hematuria (blood in urine) and inquire about abnormal vaginal bleeding in women.
- Neurological Assessment: Monitor for changes in mental status, such as confusion or dizziness, which can be signs of decreased cerebral perfusion due to blood loss.
6. Laboratory Data Review: Review relevant laboratory results to assess coagulation status.
- Complete Blood Count (CBC): Pay attention to hemoglobin and hematocrit levels, which can decrease with blood loss. Assess platelet count, as thrombocytopenia increases bleeding risk.
- Coagulation Studies: Review Prothrombin Time (PT), Partial Thromboplastin Time (PTT), and INR values to evaluate the effectiveness of the clotting cascade, especially in patients on anticoagulants or with liver disease.
- Liver Function Tests (LFTs): Elevated liver enzymes may indicate impaired liver function, which can affect clotting factor production.
- Renal Function Tests (RFTs): Abnormal kidney function can impact platelet function.
Nursing Interventions for Bleeding Risk
Nursing interventions are crucial for preventing bleeding and managing potential bleeding episodes. These interventions encompass patient education, preventative measures, and prompt treatment.
1. Patient Education on Risk Reduction: Educate the patient about specific strategies to minimize their risk of bleeding. Tailor the education to the patient’s individual risk factors and lifestyle.
- Oral Hygiene:
- Use a soft-bristled toothbrush to prevent gum trauma.
- Avoid dental picks and vigorous flossing, which can injure gums.
- Use a non-abrasive toothpaste.
- Avoidance of Rectal and Vaginal Trauma:
- Avoid rectal suppositories, enemas, and rectal thermometers, which can cause rectal mucosal damage.
- Avoid vaginal douches and tampons, which can irritate vaginal tissues, especially if thrombocytopenic.
- Bowel Management:
- Prevent constipation to avoid straining during bowel movements, which can cause hemorrhoidal bleeding. Encourage a high-fiber diet, adequate fluid intake, and stool softeners as needed.
- Avoidance of Increased Intra-abdominal Pressure:
- Avoid forceful coughing, sneezing, or nose blowing. Teach gentle techniques.
- Instruct on avoiding the Valsalva maneuver (straining during defecation or holding breath while bearing down).
- Safety Precautions:
- Use caution with sharp objects.
- Use an electric razor instead of razor blades to minimize cuts.
- Avoid contact sports or activities with a high risk of trauma.
- Ensure a safe home environment to prevent falls (e.g., remove tripping hazards, use adequate lighting, install grab bars).
- Medication Management:
- Teach the patient to read labels of over-the-counter (OTC) medications and avoid products containing aspirin or NSAIDs, unless specifically prescribed by their healthcare provider. Explain why these medications increase bleeding risk.
- Educate patients on the importance of medication adherence, particularly with anticoagulants, and the need for regular monitoring (e.g., INR checks for warfarin).
2. Education on Recognizing and Reporting Bleeding Signs: Educate the patient and family about the signs and symptoms of bleeding that require prompt reporting to a healthcare provider. Early identification and treatment are crucial to minimizing blood loss complications.
- Overt Bleeding: Visible bleeding such as nosebleeds, bleeding gums, prolonged bleeding from cuts, blood in urine or stool, heavy menstrual bleeding, vomiting blood, or coughing up blood.
- Covert Bleeding: Subtle signs like unexplained bruising, petechiae, dizziness, weakness, fatigue, shortness of breath, chest pain, abdominal pain or swelling, confusion, or changes in skin color (pallor).
- When to Seek Immediate Medical Attention: Emphasize when bleeding becomes a medical emergency, such as uncontrolled bleeding, significant blood loss, or signs of shock (dizziness, lightheadedness, confusion, rapid heart rate, low blood pressure). Provide clear instructions on who to contact and where to go for urgent care.
3. Administration of Reversal Agents and Blood Products: In cases of active bleeding or high risk of bleeding, administer reversal agents or blood products as ordered by the physician.
- Reversal Agents: For patients on anticoagulants, reversal agents may be necessary in emergency situations or prior to procedures.
- Protamine sulfate is the antidote for heparin and low molecular weight heparin (LMWH).
- Vitamin K is the antidote for warfarin.
- Idarucizumab reverses dabigatran.
- Andexanet alfa reverses factor Xa inhibitors (e.g., rivaroxaban, apixaban).
- Blood Products: Blood transfusions or blood product administration may be ordered to replace lost blood volume or blood components.
- Packed red blood cells (PRBCs) are used to increase oxygen-carrying capacity.
- Fresh frozen plasma (FFP) contains clotting factors.
- Platelets are given to treat thrombocytopenia.
- Cryoprecipitate contains fibrinogen and factor VIII.
4. Monitor Laboratory Values and Vital Signs: Closely monitor laboratory values (CBC, coagulation studies, LFTs, RFTs) and vital signs for any indications of bleeding or changes in coagulation status. Report significant changes to the healthcare provider promptly.
5. Minimize Invasive Procedures: When possible, minimize the number of invasive procedures. When necessary, use meticulous technique to minimize trauma and bleeding risk. Apply pressure to puncture sites after procedures.
6. Collaborate with the Healthcare Team: Communicate effectively with the physician, pharmacist, and other members of the healthcare team to ensure a coordinated approach to bleeding risk management. This includes discussing medication adjustments, alternative routes of medication administration, and strategies for managing underlying conditions that contribute to bleeding risk.
Nursing Care Plans for Bleeding Risk
Nursing care plans provide structured frameworks for organizing assessments, interventions, and expected outcomes. Here are three example care plans for different scenarios associated with bleeding risk.
Care Plan #1: Bleeding Risk Related to Deficient Knowledge of Bleeding Precautions
Diagnostic Statement: Risk for bleeding as evidenced by deficient knowledge of bleeding precautions.
Expected Outcomes:
- Patient will verbalize understanding of bleeding precaution strategies before discharge.
- Patient will demonstrate at least three strategies to prevent active bleeding (e.g., proper toothbrushing, safe use of razors) by discharge.
Assessment:
- Assess medical history: Note conditions increasing bleeding risk (trauma, peptic ulcer disease, liver disease). Rationale: Identifies potential bleeding risks to guide preventive measures.
- Evaluate medication regimen: Identify use of NSAIDs, anticoagulants, corticosteroids. Rationale: These medications predispose to bleeding.
- Assess knowledge of bleeding precautions: Determine current understanding and identify learning needs. Rationale: Informs development of an effective teaching plan.
Interventions:
- Instruct on injury prevention measures:
- Use a soft toothbrush and nonabrasive toothpaste.
- Avoid toothpicks and dental floss.
- Avoid rectal suppositories, enemas, thermometers, vaginal douches, and tampons.
- Avoid the Valsalva maneuver; blow nose, cough, or sneeze gently.
- Avoid contact sports or high-trauma sports.
- Use electric razor.
- Ensure safe home environment, free of clutter and hazards.
- Rationale: These strategies prevent trauma and bleeding, particularly to mucous membranes.
- Instruct on signs and symptoms of bleeding: Provide a written list and verbal explanation of bleeding signs requiring medical attention. Rationale: Early identification of bleeding reduces complication risks.
- Educate on OTC medication labels: Advise against excessive use of aspirin or NSAIDs. Rationale: These drugs increase GI irritation and bleeding risk by inhibiting platelet aggregation and affecting gastric mucosa integrity.
- Teach about safety equipment in daily activities and sports: Emphasize the importance of helmets, padding, and appropriate gear. Rationale: Reduces trauma and injury risk.
- Teach bleeding control measures for minor skin trauma: Demonstrate direct pressure application and ice pack use. Explain when to seek further medical attention versus manage at home. Rationale: Empowers patient and family to manage minor bleeding and recognize emergencies.
Care Plan #2: Bleeding Risk Related to Altered Clotting Factors
Diagnostic Statement: Risk for bleeding as evidenced by altered clotting factors.
Expected Outcomes:
- Patient will exhibit normal clotting times (PT 11-12.5 seconds, PTT 60-70 seconds) within 48 hours of intervention initiation.
- Patient will be free from signs of active bleeding (confusion, clammy skin, dizziness, hypotension, pallor, tachycardia, shortness of breath, abdominal/chest pain, skin color changes, melena, hematuria, hematemesis, abnormal uterine bleeding) throughout hospitalization.
Assessment:
- Monitor blood pressure and heart rate; note orthostatic hypotension. Rationale: Tachycardia compensates for blood loss initially. Orthostatic hypotension indicates decreased circulating volume.
- Assess skin and mucous membranes for petechiae, bruising, hematoma, and active bleeding. Rationale: Thrombocytopenia and clotting factor disorders manifest as bleeding into tissues.
- Review laboratory findings for coagulation status (PT, PTT, INR, platelet count, fibrinogen). Rationale: Identifies impaired clotting ability and bleeding risk.
Interventions:
- Be prepared to administer hemostatic agents as prescribed (e.g., Vitamin K, protamine sulfate, antifibrinolytics). Rationale: Hemostatic medications control bleeding through various mechanisms.
- Instruct patient and family on signs and symptoms of potential bleeding episodes. Rationale: Early recognition facilitates prompt medical notification and treatment.
- Teach about prescribed anticoagulant medications: Include drug name, purpose, administration instructions (with/without food), lab tests, and side effects. Rationale: Enhances medication adherence and patient knowledge.
- Administer antidotes for excessive anticoagulant use as prescribed (protamine for heparin, Vitamin K for warfarin). Rationale: Reverses anticoagulant effects in bleeding emergencies.
- Administer blood products as prescribed (plasma, platelets, cryoprecipitate). Rationale: Replaces clotting factors and blood components depending on the underlying cause.
Care Plan #3: Bleeding Risk Related to Impaired Liver Function
Diagnostic Statement: Risk for bleeding as evidenced by impaired liver function.
Expected Outcomes:
- Patient will not manifest any bleeding episodes during hospitalization.
- Patient will display improved liver function tests (AST, ALT, bilirubin, albumin) within one week of treatment initiation.
Assessment:
- Monitor vital signs, especially blood pressure and heart rate. Rationale: Changes indicate potential bleeding.
- Assess skin and mucous membranes for petechiae, bruising, hematoma, and active bleeding. Rationale: Full assessment identifies potential bleeding sites.
- Monitor abnormal laboratory data (liver function tests, CBC, coagulation factors, platelet count). Rationale: Tracks trends in liver function and bleeding risk over time.
Interventions:
- Assist with treatment of underlying conditions (cirrhosis and comorbidities) and supportive measures (fluids, electrolytes, medications, nutrients, oxygen). Rationale: Treats the root cause and supports organ function.
- Protect patient from trauma (falls, blows, lacerations). Rationale: Prevents tissue trauma and bleeding.
- Maintain patency of vascular access (IV line). Rationale: Ensures access for fluid resuscitation or blood product administration in case of bleeding.
- Educate on bleeding prevention:
- Use electric shaver.
- Avoid constipation.
- Cough or blow nose gently.
- Be careful with sharp objects.
- Apply direct pressure and ice for minor bleeding.
- Know when to contact doctor or seek emergency care.
- Rationale: Empowers patient to prevent bleeding and seek timely help.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
- Gulanick, Meg, and Judith L. Myers. Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier/Mosby, 2014.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (Eds.). (2024). NANDA-I International Nursing Diagnoses: Definitions and Classification, 2024-2026. Thieme. 10.1055/b000000928
