Assessment Nursing Scientific Planning Intervention Rationale Evaluation

Diagnosis Rationale

Subjective: Risk for bleeding After 30

related to bone minutes of
marrow infiltration nursing
as evidenced by interventions,
thrombocytopenia the client will:
(platelet count of ) INDEPENDENT:
a. Display 1. Assess for signs and 1. The GI tract is the most usual Client
homeostasis symptoms of bleeding. source of bleeding because of its maintained
as evidenced Observe color of secretions mucosal fragility and alterations in homeostasis and
by absence of and stool. homeostasis associated with displayed
bleeding. cirrhosis. absence of
bleeding.
2. Monitor pulse and BP. 2. An increased pulse with decreased
BP may indicate loss of circulating
blood volume.

3. Note changes in mentation 3. Changes may indicate decreased

and level of consciousness. cerebral perfusion secondary to
hypovolemia.

4. Observe for and report 4. Spontaneous bleeding may

epistaxis, hemoptysis, and necessitate further evaluation and
hematuria. prompt intervention.

5. Maintain a safe environment 5. Reduces accidental injury, which

– keep all necessary objects could result in bleeding.
within client’s reach and keep
bed in low position.

6. Monitor for changes such as 6. Presence of bleeding or

skin pallor or discoloration. hemorrhage may lead to circulatory
failure and shock.

7. Encourage use of soft 7. In the presence of clotting factor

toothbrush and avoiding disturbances, minimal trauma can
straining for stool. cause mucosal bleeding.
 8. Apply pressure to small 8. Reducing risk of bleeding and
bleeding or venipunctured sites hematoma.
for longer than usual.

9. Recommend avoidance of 9. Prolongs coagulation, potentiating

aspirin-containing products. risk for hemorrhage.

COLLABORATIVE:
10. Monitor hemoglobin, 10. Indicators of active bleeding, or
hematocrit, platelets, and impending complications.
clotting factors.

11. Use small needles for 11. Minimizes damage to tissues,

injections or for blood-drawing reducing risk of bleeding.
procedures.

Source: Nursing Care Plans:

Guidelines for Individualizing Client
Care Across the Lifespan, 9th
Edition.