Risk for Injury — AIDS

Nursing Diagnosis: Risk for Injury (Hemorrhage)

Risk factors may include

• Abnormal blood profile: decreased vitamin K absorption, alteration in hepatic function, presence of autoimmune antiplatelet antibodies, malignancies (KS), and/or circulating endotoxins (sepsis)

Desired Outcomes

• Display homeostasis as evidenced by absence of bleeding.

Nursing Interventions	Rationale
Avoid injections, rectal temperatures/rectal tubes. Administer rectal suppositories with caution.	Protects patient from procedure-related causes of bleeding; i.e., insertion of thermometers, rectal tubes can damage or tear rectal mucosa. Note: Some medications need to be given via suppository, so caution is advised.
Maintain a safe environment; e.g., keep all necessary objects and call bell within patient’s reach and keep bed in low position.	Reduces accidental injury, which could result in bleeding.
Maintain bedrest/chair rest when platelets are below 10,000 or as individually appropriate. Assess medication regimen.	Reduces possibility of injury, although activity needs to be maintained. May need to discontinue or reduce dosage of a drug. Note: Patient can have a surprisingly low platelet count without bleeding.
Hematest body fluids, e.g., urine, stool, vomitus, for occult blood.	Prompt detection of bleeding/initiation of therapy may prevent critical hemorrhage.
Observe for/report epistaxis, hemoptysis, hematuria, nonmenstrual vaginal bleeding, or oozing from lesions/body orifices/IV insertion sites.	Spontaneous bleeding may indicate development of DIC or immune thrombocytopenia, necessitating further evaluation and prompt intervention.
Monitor for changes in vital signs and skin color, e.g., BP, pulse, respirations, skin pallor/discoloration.	Presence of bleeding/hemorrhage may lead to circulatory failure/shock.
Evaluate change in level of consciousness.	May reflect cerebral bleeding.
Review laboratory studies, e.g., PT, aPTT, clotting time, platelets, Hb/Hct.	Detects alterations in clotting capability; identifies therapy needs. Note: Many individuals (up to 80%) display platelet count below 50,000 and may be asymptomatic, necessitating regular monitoring.
Administer blood products as indicated.	Transfusions may be required in the event of persistent/massive spontaneous bleeding.
Avoid use of aspirin products/NSAIDs, especially in presence of gastric lesions.	These medications reduce platelet aggregation, impairing/prolonging the coagulation process, and may cause further gastric irritation, increasing risk of bleeding.