Care Plan for Abnormal Bleeding

Category / Primary Body System

• Hematological System

Problem

• Resident is at risk for abdominal bleeding or bruising.

Goal

• Resident will not exhibit any unusual bruising or bleeding for 90 days.

Plan/Approach

1. Medication Management

   • Administer medications as ordered

2. Skin and Bleeding Assessment

   • Conduct weekly skin assessments
   • Assess for abdominal bleeding/bruising daily
   • Monitor for signs of bleeding in stool, gums, emesis, sputum, and urine

3. Lab Monitoring

   • Monitor lab results as ordered and report abnormalities to the physician

4. Injection Site Management

   • Rotate injection sites to prevent localized bruising and bleeding

5. Communication and Reporting

   • Notify the physician of any lab results, signs of bleeding, or bruising

Rationale

1. Medication Management

   • Proper administration of medications helps manage conditions and prevent complications that could lead to bleeding or bruising.

2. Skin and Bleeding Assessment

   • Regular skin assessments and monitoring for signs of bleeding help detect and address issues early, preventing complications.
   • Monitoring for bleeding in various bodily excretions helps identify internal bleeding promptly.

3. Lab Monitoring

   • Regular lab tests help monitor the patient's blood coagulation status and overall health, enabling timely interventions if abnormalities are detected.

4. Injection Site Management

   • Rotating injection sites prevents tissue damage and reduces the risk of localized bruising and bleeding.

5. Communication and Reporting

   • Promptly notifying the physician of any abnormalities ensures timely adjustments to the care plan and prevents complications.

Actions

1. Medication Management

   • Administer medications as per the prescribed schedule, ensuring adherence to the treatment plan.
   • Monitor for and document any side effects of medications, especially those that increase the risk of bleeding.

2. Skin and Bleeding Assessment

   • Conduct a comprehensive skin assessment weekly to check for signs of bruising or unusual marks.
   • Assess for abdominal bleeding or bruising daily, documenting findings and reporting any concerns immediately.
   • Monitor stool, gums, emesis, sputum, and urine for signs of bleeding and document findings.

3. Lab Monitoring

   • Draw and analyze lab tests as ordered, such as complete blood count (CBC) and coagulation profile, reporting results to the physician.
   • Track and document lab results to identify trends or changes that may indicate a risk of bleeding.

4. Injection Site Management

   • Rotate injection sites regularly, ensuring that each site has adequate time to heal before reuse.
   • Inspect injection sites for signs of bruising or bleeding and report any issues.

5. Communication and Reporting

   • Notify the physician immediately of any abnormal lab results, signs of bleeding, or unusual bruising.
   • Maintain clear and accurate documentation of all assessments, findings, and communications with the healthcare team.