- Cerebrovascular accident
- Liver damage
- Invasive procedures
- Gastrointestinal disease
- Clotting dysfunction/disorders
- Pregnancy complications
- Deficient knowledge
- Frequent falls
- The patient will remain free from signs of bleeding
- The patient will have a stable hemoglobin and hematocrit during the hospital stay
- The patient will be able to name risk factors of bleeding
- The patient will adhere to precautions to minimize the risk of bleeding
- The patient will be compliant with medication regimens
|Assess the patient’s past medical history and note diseases that might pose a higher risk for bleeding. The following conditions, among others, may contribute to a higher risk of bleeding. |
Any condition or organ that affects blood formation or platelet formation and alters coagulation abilities might contribute to a higher risk of bleeding. Identifying potential risk allows for the early implementation of preventative measures.
|Perform a fall risk assessment on admission using a fall risk assessment tool. Consider|
History of falls
Lines and devices
Mode of elimination
Fall risk assessment tools help identify the level of measures that need to be implemented to keep the patient safe.
|Complete a medication reconciliation and note medications that can contribute to the risk for bleeding. |
Blood thinners (e.g., Warfarin, Heparin)
NSAIDs (e.g., Ibuprofen)
Salicylates (e.g., Aspirin)
Chemotherapy drugs Steroids Selective serotonin reuptake inhibitors or, in short, SSRIs (e.g., Sertraline)
Supplements (e.g., garlic, ginger)
Aspirin and NSAIDs inhibit inflammatory processes such as platelet aggregation, Warfarin interferes with the formation of vitamin K-dependent clotting factors, and chemotherapy drugs can affect the bone marrow, where platelets are produced. SSRIs prevent platelet aggregation. Heparin interferes with the clotting cascade preventing the conversion of fibrinogen to fibrin.
|Monitor vital signs frequently. |
Changes in blood pressure and heart rate could be indications for internal bleeding. An increase in heart rate and decreased blood pressure may be a sign of blood loss in the vascular system. Blood loss reduces vascular volume leading to low blood pressure, whereas an increased heart rate is a compensatory attempt of the body to pump blood faster through the system to make up for lost volume.
|Check orthostatic vital signs per order. |
Orthostasis can occur from low vascular volume. A patient is positive for orthostatic hypotension if the systolic blood pressure drops by 20mmHg and the diastolic blood pressure by 10mmHg when changing from lying down to sitting up or standing up. Expect the patient to feel dizziness or lightheadedness.
|Monitor the patient for signs of increased bleeding or hemorrhage. |
Bloody urine (hematuria)
Tarry, dark stools (melena)
Bleeding of surgical incisions
Nose bleeds (epistaxis)
Changes in level of consciousness
Signs and symptoms of shock
Any of these signs may indicate bleeding. Further investigation is warranted. Note frequency and amount.
|Monitor coagulation studies frequently. |
Partial Thromboplastin Time (PTT)
Prothrombin time (PT)
International Normalized Ratio (INR)
Activated Coagulation Time (ACT)
Increased values may indicate an increased risk for bleeding. These values also aid in adjustments of medication dosages such as heparin shots, infusions, and Warfarin.
|Monitor hematocrit and hemoglobin regularly. |
Patients might be asymptomatic despite losing blood. These values allow early identification of blood loss.
|Obtain occult stool and urine samples as ordered. |
Occult tests detect blood that is not visible with the naked eye.
Nursing Interventions for Risk for Bleeding
|Anticipate the administration of blood products and volume expanders if indicated and ordered. |
Blood administration and other products and fluids such as saline or albumin help restore circulating volume in the vascular system. Products to be given may include red blood cells, fresh frozen plasma, platelets, and cryoprecipitate.
|Keep antidotes available on the unit. |
Protamine sulfate is the antidote for heparin. Vitamin K reverses the effects of Warfarin.
|If bleeding occurs, hold pressure on the site until the bleeding is controlled. |
Pressure devices and dressings may be used if indicated.
|Ensure adequate staffing to monitor patients that are at higher risk for bleeding adequately. |
Sufficient personnel allows for closer and more frequent observation and promotes safety.
|Obtain baseline laboratory studies. |
This information is essential for the initiation of anticoagulant therapy.
|Check laboratory tests before administration. |
Lab values such as INR or platelet count can change quickly. Medication that was appropriate one day might not be suitable the next day. Trending these lab values ensures proper monitoring and dosing.
|Collaborate with the dietitian to adjust portions of certain foods to avoid counteracting anticoagulation therapy. |
Foods such as spinach, kale, collard greens, and brussels sprouts may interfere with warfarin therapy because these foods contain vitamin K.
|Perform frequent neuro checks on the patient. |
Blood loss reduces the number of oxygen-carrying red blood cells leading to decreased oxygenation of organs, especially the brain. These changes might lead to a reduced neurological function.
|Teach the patient to use a soft-bristled toothbrush and avoid floss and toothpicks. |
Soft toothbrushes decrease the risk of irritating the gum tissue and cause bleeding. Flossing and using toothpicks might cause trauma to gums and cause bleeding.
|Encourage male patients to use an electric shaver or clippers. |
Electric shavers and clippers are less likely to cause trauma to tissues.
|Teach patients to avoid blowing their nose forcefully, sneezing, coughing, or straining with bowel movements. |
These activities can cause trauma to mucosal linings.
|Teach the patient and family to hold pressure for at least 5 to 10 minutes if bleeding occurs. |
The patient and family need to know what to do when the patient is bleeding. Knowledge about which actions to take in critical situations may reduce the number of hospitalizations.
|Advise the patient to avoid situations that could cause injury or bleeding, such as contact sports or dealing with sharp objects such as knives and scissors. |
The patient needs to learn to recognize situations that could cause tissue trauma and bleeding.
|Emphasize the importance of taking medications at the same time each day. |
Taking medications at the same time ensures to maintain a certain level of the drug in the body.
|Teach about dietary considerations. |
It is important to keep the amount of green leafy vegetables containing vitamin K consistent. Increasing or decreasing the amount of these foods might need a dosage adjustment.
|Encourage the patient to increase fluid intake if not contraindicated and eat a diet high in fiber to reduce instances of constipation. |
Hard and dry feces may cause trauma to mucous membranes of the colon and rectum.
|Teach the patient to monitor stools for color and consistency. |
Black tarry stools might indicate an upper gi bleed, whereas bright red color might mean a lower gi bleed.
|Teach the patient to read medication labels when taking over the counter medicine. Avoid taking NSAIDs, aspirin, and other salicylates while taking blood thinners unless specifically ordered by the physician. |
Taking these medications in addition to prescribed blood thinners and antiplatelet medicine may increase the risk of bleeding.
|Remind the patient to inspect the skin and mucous membranes regularly for bleeding. |
By monitoring the skin frequently, early detection of bleeding and possible coagulation abnormalities is possible.
|Teach the patient and family about the use of herbals. |
Some herbals and supplements might increase the risk of bleeding. Examples are ginger, ginkgo biloba, chamomile, and feverfew. Some of these herbals possess antiplatelet properties, and some increase anticoagulation.
|Advise the patient to keep follow-up appointments to monitor the effects of anticoagulant therapy. |
Regular lab tests promote safety and allow the physician to make adjustments if necessary.
|Instruct the patient to let his or her dentist know about anticoagulant therapy before any procedures. |
Dental work may involve invasive procedures that can cause trauma and bleeding.
|Have the patient wear an ID bracelet stating anticoagulant therapy. |
This information can be taken into consideration during an emergency in which the patient might be unresponsive.
|Teach about signs and symptoms that require medical attention. |
Knowing the signs of bleeding and hematoma formation allows for quick intervention and promotes safety.
|Provide verbal and written material about the education points of anticoagulant therapy. |
Written material allows the patient and family to refer back and review information at any time. Both forms of education can reinforce learned material and help the patient, and family members better understand health information.
More Care Plans:
Liabeuf, S., Scaltieux, L., Masmoudi, K., Roussel, B., Moragny, J., Andrejak, M., & Gras-Champel, V. (2015). Risk Factors for Bleeding in Hospitalized at Risk Patients With an INR of 5 or More Treated With Vitamin K Antagonists. Medicine, 94(52), e2366. doi: 10.1097/md.0000000000002366
Example of a fall risk assessment tool:
Do SSRIs cause gastrointestinal bleeding?. (2004). Drug And Therapeutics Bulletin, 42(3), 17-18. doi: 10.1136/dtb.2004.42317
Deglin, J., Vallerand, A., & Sanoski, C. (2014). Davis’s Drug Guide for Nurses (14th ed.) (14th ed.). FA Davis Company.
Low Blood Pressure (Orthostatic Hypotension): Causes, Symptoms & Treatments. (2020).https://my.clevelandclinic.org/health/diseases/9385-low-blood-pressure-orthostatic-hypotension#:~:text=Orthostatic%20hypotension%20is%20a%20sudden,is%20also%20called%20postural%20hypotension.
Blair, M., Ignatavicius, D., Rebar, C., Winkelman, C., & Workman, M. Medical-surgical nursing (8th ed.). Elsevier.