Abnormal Bleeding

Category / Primary Body System

• Hematologic / Circulatory System

Problem

• Patient is at risk for abdominal bleeding or bruising.

Goal

• Patient will not exhibit any unusual bruising or bleeding for the next 90 days.

Plan/Approach

1. Medication Management

   • Administer medications as ordered to manage underlying conditions and minimize the risk of bleeding.

2. Skin and Bleeding Assessment

   • Conduct weekly skin assessments to monitor for signs of bruising or bleeding.
   • Assess for abdominal bleeding/bruising regularly to detect any early signs of bleeding.

3. Lab Monitoring

   • Monitor labs as ordered to track relevant blood parameters and detect any abnormalities early.

4. Injection Site Management

   • Rotate injection sites to prevent localized bruising or bleeding and reduce tissue damage.

5. Bleeding Surveillance

   • Monitor stool, gums, emesis, sputum, and urine for signs of bleeding to identify any internal bleeding early.

6. Notification Protocol

   • Notify the physician of lab results, bleeding, or bruising immediately to ensure timely intervention.

Rationale

1. Medication Management

   • Proper administration of medications helps manage conditions that may predispose the patient to bleeding, such as blood thinners or anticoagulants.

2. Skin and Bleeding Assessment

   • Regular skin and abdominal assessments allow for early detection of bruising or bleeding, enabling prompt intervention.

3. Lab Monitoring

   • Regular lab tests can help detect changes in blood clotting factors and other relevant parameters, facilitating early detection and management of bleeding risks.

4. Injection Site Management

   • Rotating injection sites prevents the development of hematomas and reduces the risk of tissue damage and bruising.

5. Bleeding Surveillance

   • Monitoring for signs of bleeding in bodily excretions helps identify internal bleeding early, allowing for prompt medical response.

6. Notification Protocol

   • Immediate notification of the physician ensures that any signs of bleeding or abnormal lab results are addressed quickly, preventing complications.

Actions

1. Medication Management

   • Administer medications as prescribed and document administration and any side effects.
   • Review medications regularly with the healthcare team to ensure they are appropriate and adjust as necessary.

2. Skin and Bleeding Assessment

   • Perform weekly skin assessments, documenting any findings and reporting abnormalities.
   • Conduct regular assessments for abdominal bleeding/bruising, documenting findings and reporting any concerns immediately.

3. Lab Monitoring

   • Draw labs as ordered, reviewing and reporting results to the healthcare team promptly.
   • Track relevant lab parameters closely to detect any trends or abnormalities.

4. Injection Site Management

   • Rotate injection sites regularly, documenting locations and monitoring for signs of irritation or bruising.

5. Bleeding Surveillance

   • Monitor stool, gums, emesis, sputum, and urine for signs of bleeding, documenting and reporting findings immediately.

6. Notification Protocol

   • Notify the physician immediately of any lab results indicating abnormal bleeding or any physical signs of bleeding or bruising.