Risk for Injury: Bleeding r/t decreased platelet count Reviewed by Momizat on . Cues Objective: - last platelet result of 119 - irritable - with a actual vital signs of: Temp: RR: PR: HR: BP: - IVF of: - few bruises in the lower extremities Cues Objective: - last platelet result of 119 - irritable - with a actual vital signs of: Temp: RR: PR: HR: BP: - IVF of: - few bruises in the lower extremities Rating:
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Risk for Injury: Bleeding r/t decreased platelet count

Cues

Objective:

- last platelet result of 119

- irritable

- with a actual vital signs of:

Temp:

RR:

PR:

HR:

BP:

- IVF of:

- few bruises in the lower extremities.

Need

Health Perception/ Health Management Pattern

Nursing Diagnosis

Risk for Injury: Bleeding related to decreased platelet count.

R: Thrombocytopenia (low platelet level) can result in various factors: decreased production of platelets, or increased destruction of platelets, or increased consumption of platelets. This disorder results from the circulating antiplatelet autoantibodies that bind to the patient’s antibodies. The body attempts to compensate for this destruction by increasing platelet production. Its common manifestations are easy bruising, heavy menses, or petechiae.

Objectives of Care

Within 8 hours span of care, patient will  be free from injury as evidenced by:

a. VS within the normal range.

Temp: 35.6-36.7 C

RR: 16-20cpm

PR: 80-90bom

BP- 130/90-110/70 mmHg

b. Demonstrate behaviours (lifestyle changes to reduce risk factors and protect self from injury);

c. Modify environment to enhance safety; and

d. Verbalize understanding of factors that contribute to possibility of injury.

Interventions

1. Assess mood, coping abilities, and personality styles.

R: to evaluate the degree/source risk inherent to the individual.

2. Provide information regarding the condition that may result in risk for injury.

R: to promote awareness

3. Monitor pulse, Blood pressure.

R: An increase in pulse with decreased Blood pressure can indicate loss of circulating blood volume and may point out to bleeding.

4. Check on patient at least every 2 hours.

R: this is a primary preventive measure to ensure patient safety.

5. Keep bed in low position and at least 30 degrees

R: to reduce risk factors, injury.

6. Keep the patient’s room free from clutter.

R: to promote individual safety.

7. Assist patient with transfer/ambulation.

R: to aid in preventing from tripping off on the floor or from the bed.

8. Encourage use of soft toothbrush, avoiding straining for stool, and forceful nose blowing.

R: Minimizes damage to tissues, reducing risk for bleeding

9. Recommend avoidance of aspirin containing products.

R: Prolongs coagulation, potentiating risk of hemorrhage.

10. Emphasize the importance of safety measures

R: This promotes education and increases the awareness of the client on the condition.

Evaluation

At the end of 8 hours span of care, patient was able to be free from injury as evidenced by:

a. VS within the normal range

b. Demonstrating corrective measure such as avoid using too much force upon toothbrushing; and

c. Modifying the environment by removing mess in her/him room that might cause injury to her/him.