PATIENT NAME : DIAGNOSIS : PROBLEM

ROOM : IMPLEMENTATION MORNING

ID NUMBER :

NURSING

INTERVENTION

EVALUATION SIG N S: NOON SIG N S: NIGHT SIG N

Risk for bleeding related to : Pregnancy or postpartumrelated complications Treatment-related side effects Circumcision Disseminated intravascular coagulopathy Inherent coagulopathies GI disorders Aneurysm Impaired liver function Trauma or history of falls

Expected outcomes : The patient will : Receive screening to alert about existing risk factors for bleeding. Maintain homeostasis with absence of bleeding. Identify and avoid risk situations with potential for trauma injury. Criteria result : Blood less severity Maintain heart rate, rhythm, blood pressure, stabilization of Hgb and Hct and tissue perfusion Demonstrate improved fluid balance, adequate urinary output, moist mucous membranes, good skin turgor, and prompt capillary refill. Intervention : 1. Interview/screen each client for risk factors for bleeding 2. Anticipate conditions and episodes of care that may precipitate bleeding

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especially in high-risk patient care areas 3. Monitor physiologic responses for values that exceed expected or normal ranges 4. Monitor for occult and for frank bleeding (urine, feces, wounds, and dressings) 5. Perform vital signs and basic physical assessments for the patient who is at risk for bleeding. 6. Obtain laboratory tests (hemoglobin, hematocrit, complete blood cell count, thrombin time, prothrombin time, activated partial thromboplastin time, etc.) 7. Teach patient about intended and unintended effects of medications that increase the risk of bleeding or prolong clotting. 8. Discuss patterns of risk management to promote a lifestyle that focuses on health promotion/injury avoidance to diminish injuries .9. Discuss alternatives in ADLs to avoid trauma-causing injury and bleeding.10. Provide care protecting an individual from injury to prevent bleeding 11. Provide emotional support

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to the patient who is bleeding and is experiencing physiologic compensatory responses of anxiety, fear, and a sense of dread 12. Support participation in decisions about the treatment placing the patient at risk for bleeding.