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. |
