related to bone minutes of marrow infiltration nursing as evidenced by interventions, thrombocytopenia the client will: (platelet count of ) INDEPENDENT: a. Display 1. Assess for signs and 1. The GI tract is the most usual Client homeostasis symptoms of bleeding. source of bleeding because of its maintained as evidenced Observe color of secretions mucosal fragility and alterations in homeostasis and by absence of and stool. homeostasis associated with displayed bleeding. cirrhosis. absence of bleeding. 2. Monitor pulse and BP. 2. An increased pulse with decreased BP may indicate loss of circulating blood volume.
3. Note changes in mentation 3. Changes may indicate decreased
and level of consciousness. cerebral perfusion secondary to hypovolemia.
4. Observe for and report 4. Spontaneous bleeding may
epistaxis, hemoptysis, and necessitate further evaluation and hematuria. prompt intervention.
5. Maintain a safe environment 5. Reduces accidental injury, which
– keep all necessary objects could result in bleeding. within client’s reach and keep bed in low position.
6. Monitor for changes such as 6. Presence of bleeding or
skin pallor or discoloration. hemorrhage may lead to circulatory failure and shock.
7. Encourage use of soft 7. In the presence of clotting factor
toothbrush and avoiding disturbances, minimal trauma can straining for stool. cause mucosal bleeding. 8. Apply pressure to small 8. Reducing risk of bleeding and bleeding or venipunctured sites hematoma. for longer than usual.
9. Recommend avoidance of 9. Prolongs coagulation, potentiating
aspirin-containing products. risk for hemorrhage.
COLLABORATIVE: 10. Monitor hemoglobin, 10. Indicators of active bleeding, or hematocrit, platelets, and impending complications. clotting factors.
11. Use small needles for 11. Minimizes damage to tissues,
injections or for blood-drawing reducing risk of bleeding. procedures.
Source: Nursing Care Plans:
Guidelines for Individualizing Client Care Across the Lifespan, 9th Edition.