Nursing Diagnosis: Risk for Bleeding - A Comprehensive Care Plan

Bleeding risk, clinically defined as the potential for a decrease in blood volume that could compromise health, is a significant concern in patient care. Effective assessment and well-planned interventions are crucial to preventing bleeding episodes and promptly addressing complications if they arise, ultimately enhancing patient outcomes. This article delves into the “Risk for Bleeding” nursing diagnosis, providing a detailed care plan designed to guide healthcare professionals in managing and mitigating this risk.

Risk Factors for Bleeding

Identifying specific risk factors in each patient is the cornerstone of implementing targeted and effective preventive measures. Understanding these factors allows nurses to tailor interventions to address the unique needs of their patients. Common risk factors associated with an increased risk for bleeding include:

Medications: Anticoagulants (like warfarin, heparin, and direct oral anticoagulants), antiplatelet drugs (such as aspirin, clopidogrel), Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), thrombolytics, and certain chemotherapy agents all interfere with the body’s natural clotting mechanisms.
Medical Conditions:
- Thrombocytopenia: A decreased platelet count, which can be caused by various conditions including leukemia, chemotherapy, and autoimmune disorders, impairs blood clotting.
- Liver Disease: The liver plays a critical role in producing clotting factors. Impaired liver function can lead to a deficiency in these factors, increasing bleeding risk.
- Hemophilia and other Coagulation Disorders: Inherited conditions that impair the body’s ability to form blood clots.
- Von Willebrand Disease: A genetic disorder that affects the von Willebrand factor, a protein necessary for blood clotting.
- Disseminated Intravascular Coagulation (DIC): A serious condition characterized by abnormal activation of the clotting cascade, leading to both clotting and bleeding.
- Gastrointestinal Conditions: Peptic ulcers, gastritis, esophageal varices, and inflammatory bowel disease can cause gastrointestinal bleeding.
- Kidney Disease: Severe kidney disease can affect platelet function and increase bleeding risk.
- Cancer: Certain cancers, especially leukemia and metastatic cancers, can increase bleeding risk due to bone marrow suppression or tumor-related coagulopathies.
- Aneurysm: Weakened blood vessel walls are prone to rupture and cause hemorrhage.
Procedures and Treatments:
- Surgery: Surgical procedures, especially major surgeries, inherently carry a risk of bleeding.
- Trauma: Physical injuries can cause blood vessel damage and bleeding.
- Invasive Procedures: Procedures like biopsies, lumbar punctures, and central line insertions increase the risk of bleeding at the insertion site.
- Chemotherapy and Radiation Therapy: These treatments can suppress bone marrow function, leading to thrombocytopenia and increased bleeding risk.
- Extracorporeal Membrane Oxygenation (ECMO) and Hemodialysis: These treatments often require anticoagulation, increasing bleeding risk.
Patient History:
- Previous Bleeding Episodes: A history of bleeding disorders or unexplained bleeding increases the index of suspicion.
- Age: Elderly patients may have increased bleeding risk due to age-related physiological changes and polypharmacy.
- Nutritional Deficiencies: Vitamin K deficiency, for example, can impair clotting factor synthesis.

Note: A “risk for” diagnosis is preventative. It’s identified by risk factors, not by existing signs and symptoms of the problem itself. Nursing interventions are therefore focused on prevention.

Expected Outcomes

The primary goals for a patient diagnosed with “Risk for Bleeding” are centered on preventing bleeding episodes and empowering the patient with knowledge about bleeding precautions. Measurable expected outcomes include:

Absence of Bleeding: The patient will not experience any bleeding episodes, as evidenced by:
- Hemoglobin and hematocrit levels within the patient’s normal range.
- Prothrombin Time (PT) and International Normalized Ratio (INR) values within therapeutic or normal limits.
- Blood pressure and heart rate within the patient’s baseline normal range.
- Absence of overt signs of bleeding such as bruising, petechiae, hematuria, melena, or hematemesis.
Understanding of Bleeding Precautions: The patient will verbally articulate an understanding of specific measures to prevent bleeding in their daily life and during healthcare procedures.
Recognition of Bleeding Signs: The patient will verbalize the ability to recognize the signs and symptoms of bleeding that necessitate immediate reporting to a healthcare provider.

Nursing Assessment

A thorough nursing assessment is the first and most crucial step in developing a comprehensive care plan. This assessment involves gathering subjective and objective data to identify individual risk factors and establish a baseline.

1. Detailed Medical History Review: Assess the patient’s past and present medical history for conditions that predispose them to bleeding. This includes:

Known bleeding disorders (hemophilia, von Willebrand disease).
Liver disease (cirrhosis, hepatitis).
Kidney disease (chronic kidney disease, renal failure).
Gastrointestinal disorders (peptic ulcer disease, gastritis, inflammatory bowel disease).
Cancer (leukemia, metastatic disease).
History of aneurysm or vascular malformations.
Previous surgeries or traumatic injuries.
Obstetrical history, including postpartum complications or bleeding during pregnancy.

2. Medication Reconciliation and Review: Carefully review all medications the patient is currently taking, including prescription drugs, over-the-counter medications, and herbal supplements. Pay particular attention to:

Anticoagulants (warfarin, heparin, DOACs).
Antiplatelet agents (aspirin, clopidogrel, ticagrelor).
NSAIDs (ibuprofen, naproxen, ketorolac).
Thrombolytics (alteplase, tenecteplase).
Certain antibiotics and chemotherapy drugs known to affect platelet function or bone marrow.
Herbal supplements that may have anticoagulant or antiplatelet effects (ginger, ginkgo biloba, garlic).

3. Vital Signs Monitoring: Regularly monitor vital signs, specifically blood pressure and heart rate. Be alert for:

Tachycardia: An elevated heart rate can be an early compensatory mechanism for blood loss.
Hypotension: Low blood pressure is a later sign of significant blood loss and indicates hemodynamic instability.
Narrowing Pulse Pressure: A reduced difference between systolic and diastolic blood pressure can also be an indicator of hypovolemia.

4. Assessment for Orthostatic Hypotension: Evaluate for orthostatic hypotension by measuring blood pressure and heart rate in supine, 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 upon standing can indicate:

Reduced blood volume, potentially due to occult bleeding.
Increased risk of falls, which could lead to trauma and subsequent bleeding, especially in patients with bleeding risk factors.

5. Physical Examination for Signs of Bleeding: Conduct a thorough physical examination, looking for both overt and subtle signs of bleeding:

Skin and Mucous Membranes: Inspect for:
- Bruising (Ecchymosis): Discoloration of the skin due to blood leaking under the tissues. Note the size, location, and any pattern.
- Petechiae: Small, pinpoint-sized red or purple spots on the skin, indicating capillary bleeding.
- Purpura: Larger areas of reddish-purple discoloration, resulting from more extensive bleeding under the skin.
- Hematoma: Localized collection of blood outside the blood vessels, often appearing as a raised, swollen area.
- Pallor: Pale skin or mucous membranes, suggesting anemia due to blood loss.
- Active Bleeding: Observe for any active bleeding from wounds, IV sites, mucous membranes (nosebleeds, gum bleeding), or surgical sites.
Gastrointestinal System: Assess for:
- Abdominal Distention or Tenderness: May indicate internal bleeding.
- Melena: Black, tarry stools, indicating digested blood in the stool from upper GI bleeding.
- Hematemesis: Vomiting blood, which can be bright red (fresh blood) or coffee-ground emesis (digested blood).
- Rectal Bleeding: Bright red blood per rectum, often from lower GI bleeding or hemorrhoids.
Genitourinary System:
- Hematuria: Blood in the urine, which can be visible (gross hematuria) or microscopic.
- Vaginal Bleeding: Abnormal or excessive vaginal bleeding in women.
Neurological System: Assess for signs of intracranial bleeding:
- Changes in Level of Consciousness: Confusion, lethargy, restlessness.
- Headache: Especially sudden onset and severe.
- Pupillary Changes: Unequal or sluggishly reactive pupils.
- Weakness or Paralysis: Focal neurological deficits.
Respiratory System:
- Hemoptysis: Coughing up blood.
- Shortness of Breath: May indicate anemia or blood loss into the lungs (pulmonary hemorrhage).

6. Review Laboratory Data: Evaluate relevant laboratory results, particularly:

Complete Blood Count (CBC):
- Hemoglobin and Hematocrit: Low levels indicate anemia, which may be due to blood loss.
- Platelet Count: Thrombocytopenia (low platelet count) significantly increases bleeding risk.
Coagulation Studies:
- Prothrombin Time (PT) and International Normalized Ratio (INR): Prolonged PT/INR indicates impaired extrinsic and common coagulation pathways, often seen in patients on warfarin or with liver disease.
- Partial Thromboplastin Time (PTT): Prolonged PTT indicates impaired intrinsic and common coagulation pathways, often seen in patients on heparin or with hemophilia.
- Fibrinogen Level: Low fibrinogen levels can impair clot formation.
Liver Function Tests (LFTs): Elevated liver enzymes (AST, ALT) and bilirubin, and decreased albumin can indicate impaired liver function and reduced clotting factor production.
Renal Function Tests (BUN, Creatinine): Elevated BUN and creatinine may indicate kidney disease, which can contribute to bleeding risk.

Nursing Interventions

Nursing interventions for “Risk for Bleeding” are focused on prevention, early detection, and prompt management of bleeding episodes.

1. Implement Bleeding Precautions and Risk-Reduction Strategies: Educate and implement measures to minimize trauma and reduce the potential for bleeding:

Gentle Handling and Skin Care:
- Handle patients gently during repositioning, transfers, and procedures to prevent skin tears and bruising.
- Use lift sheets for repositioning to minimize friction and shear.
- Apply skin moisturizers to prevent dry, fragile skin.
Oral Care:
- Use a soft-bristled toothbrush for oral hygiene.
- Avoid dental floss and toothpicks, which can injure gums.
- Instruct the patient to avoid vigorous brushing and to use gentle mouthwash.
Avoid Invasive Procedures When Possible:
- Minimize intramuscular (IM) injections. If necessary, use the smallest gauge needle and apply prolonged pressure after injection.
- Avoid rectal thermometers, suppositories, and enemas, which can cause rectal trauma.
- Avoid vaginal douches and tampons.
Prevent Constipation and Straining:
- Encourage adequate fluid intake, fiber-rich diet, and stool softeners as needed to prevent constipation and straining during bowel movements.
- Instruct the patient to avoid the Valsalva maneuver (straining).
Cough and Sneeze Precautions:
- Instruct the patient to avoid forceful coughing, sneezing, or blowing the nose.
- Teach gentle techniques for coughing and sneezing.
Safety Measures to Prevent Injury:
- Use electric razors instead of safety razors.
- Advise against playing contact sports or activities with a high risk of trauma.
- Ensure a safe environment to prevent falls (clear pathways, adequate lighting, bed alarms for high-risk patients).
- Pad side rails for patients at risk of seizures or altered mental status.
Pressure Application for Bleeding:
- Teach the patient and family how to apply direct pressure to any bleeding site for 5-10 minutes.
- Use pressure dressings as needed for wounds or puncture sites.
- Apply ice packs to minor injuries to reduce swelling and bruising.

2. Patient and Family Education on Bleeding Signs and Symptoms: Educate the patient and family to recognize and report signs of bleeding promptly:

Verbalize and provide written materials detailing signs and symptoms of bleeding that require immediate medical attention:
- Unusual bruising or unexplained petechiae or purpura.
- Nosebleeds (epistaxis) that are difficult to stop.
- Bleeding gums, especially with brushing or flossing.
- Blood in the urine (hematuria) or stools (melena or hematochezia).
- Vomiting blood (hematemesis) or coffee-ground emesis.
- Coughing up blood (hemoptysis).
- Unusually heavy menstrual bleeding or bleeding between periods.
- Dizziness, lightheadedness, weakness, or fatigue (signs of blood loss).
- Sudden onset of severe headache or neurological changes.
- Abdominal pain or swelling.
Emphasize the importance of immediate reporting of any of these signs to a healthcare provider.
Instruct when bleeding becomes a medical emergency (e.g., uncontrolled bleeding, significant blood loss symptoms).

3. Medication Management and Antidote Administration:

Administer reversal agents or blood products as prescribed by the physician for patients experiencing active bleeding or at high risk:
- Antidotes:
  - Protamine sulfate: Antidote for heparin overdose.
  - Vitamin K: Antidote for warfarin overdose.
  - Idarucizumab: Reversal agent for dabigatran (direct thrombin inhibitor).
  - Andexanet alfa: Reversal agent for factor Xa inhibitors (rivaroxaban, apixaban).
  - PCC (Prothrombin Complex Concentrate): May be used to reverse warfarin and factor Xa inhibitors in emergencies.
- Blood Products:
  - Packed red blood cells (PRBCs): To replace lost red blood cell volume and improve oxygen-carrying capacity.
  - Fresh frozen plasma (FFP): Contains clotting factors to correct coagulation deficiencies.
  - Platelets: To increase platelet count in thrombocytopenic patients.
  - Cryoprecipitate: Contains fibrinogen and factor VIII, used in specific bleeding disorders.
Monitor patient response to reversal agents and blood product administration.
Ensure timely administration of prescribed medications.

4. Education on Over-the-Counter Medications:

Instruct patients to carefully read labels of all over-the-counter (OTC) medications.
Advise them to avoid products containing aspirin or NSAIDs (ibuprofen, naproxen, ketoprofen) unless specifically approved by their healthcare provider.
Explain that these medications inhibit platelet function and increase the risk of bleeding, particularly gastrointestinal bleeding.
Recommend acetaminophen (paracetamol) as a safer alternative for pain relief and fever reduction in patients at risk for bleeding, unless contraindicated.

Nursing Care Plans Examples

Here are two sample nursing care plans for “Risk for Bleeding,” illustrating different contributing factors.

Care Plan #1: Risk for Bleeding 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 by discharge.
Patient will demonstrate at least three strategies to prevent active bleeding before discharge.

Assessment:

Assess patient’s medical history: Note conditions increasing bleeding risk (trauma, peptic ulcer disease, liver disease, etc.) to guide preventive measures.
Evaluate medication regimen: Identify medications (NSAIDs, anticoagulants, corticosteroids) that predispose to bleeding.
Assess knowledge of bleeding precautions: Determine knowledge gaps to create an effective teaching plan.

Interventions:

Instruct patient about 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 risk sports.
Instruct about signs and symptoms of bleeding: Early identification reduces complication risk.
Encourage reading OTC medication labels: Advise against excessive aspirin or NSAID use to prevent GI irritation and bleeding.
Teach patient and family about precautions and safety equipment: Reduces trauma and injury risk in daily activities.
Teach patient and family bleeding control measures for superficial skin trauma: Application of direct pressure and ice packs; instruct when to seek further medical attention.

Care Plan #2: Risk for Bleeding related to Altered Clotting Factors

Diagnostic Statement: Risk for bleeding as evidenced by altered clotting factors.