00206 Bleeding Risk

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: 00206
Nanda label: bleeding risk
Diagnostic focus: bleeding
Approved 2008 • Revised 2013, 2017 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

The Nanda nursing diagnosis « bleeding risk » is defined as: susceptible to decreased blood volume, which can compromise health.

Risk factors

  • Inappropriate knowledge of precautions against bleeding

Risk population

  • People with a history of falls

Associated problems

  • Aneurysm
  • Circumcision
  • Disseminated intravascular coagulopathy
  • Gastrointestinal Problem
  • Deterioration of liver function
  • Essential coagulopathy
  • Postpartum complications
  • Complications of pregnancy
  • Trauma
  • Therapeutic regime

Suggestions of use

  • If nursing staff cannot take independent actions to avoid bleeding from a particular patient, the use of a collaborative problem diagnosis could be considered (for example, surgery complication: bleeding or bleeding). Ly>

NOC Results

  • Circulation status: Unidirectional blood flow without obstacles, with adequate pressure, through the large vessels of systemic and pulmonary circuits
  • Service of blood loss: gravity of bleeding or internal or external bleeding

Evaluation objectives and criteria

Examples with the use of terms no c

  • • Abnormal bleeding is not presented, which is manifested by a state of normal circulation and by the absence of signs of gravity of blood loss.
  • • Demonstrates absence, or only minimal presence, of gravity of blood loss (specify from 1 to 5: severe, substantial, moderate, light or none):
    • Notorious blood loss
    • Hematuria
    • Post -surgical bleeding
    • Decrease in systolic or diastolic blood pressure
    • Increase in apical heart rate
    • Pallidity of the skin and mucous membranes
    • Decrease in hemoglobin (HGB)
    • Hematocrit decrease (HCT)

Other examples

The patient may:

  • • Present minimal or non -observable blood loss (for example, does not require more than a dressing every four hours)
  • • Show blood pressure, pulse and breathing within normal limits
  • • (in postparto) uterus firm to the touch
  • • Do not show signs of hematemesis
  • • Do not present abdominal distension

NIC Interventions

  • Incision site care: cleaning, control and facilitation of healing a wound closed by suture, clips or staples
  • Circumcision care: support for men before and after being subject to circumcision
  • postpartum care: surveillance and management of the patient who has just given birth
  • Hemorrhage prevention: reduction of stimuli that can cause bleeding or bleeding in patients at risk
  • Surveillance: Collection, interpretation and synthesis of patient data, continuously and with an end, to make clinical decisions

Nursing Activities

Valuations

  • • Watch if incisions and wounds have bleeding
  • • Monitor the wound healing process
  • • Monitor presence of bleeding in dressings
  • • Monitor vital signs, especially blood pressure and pulse, as indicated by the level of risk
  • • Review hemoglobin and hematocrit levels
  • • Conduct coagulation studies
for postpartum patients:

  • • Regularly review the height and firmness of the bottom of the uterus
  • • Verify the presence of red blood and clots in loquios

Patient and family education

  • • Instruct the bleeding signals and indicate that the nursing professional should be notified in case of bleeding
  • • (NIC) Incision site care: teach the patient to reduce pressure on the incision site
For patients with coagulation problems:

  • • Indicate that the use of anticoagulants (aspirin or ibuprofen) should be avoided
  • • Instruct on an increase in the intake of foods rich in vitamin K

Collaboration activities

  • • Manage blood products as indicated

Others

  • • If the patient actively bleeds, maintain bed
For patients with coagulation problems:

  • • Do not take the rectal temperature if the patient is risk of bleeding
  • • Use electric razor
  • • For oral hygiene, use a soft toothbrush
  • • Avoid the application of injections (to patients with coagulation problems)