Quote from iowanursingstudent
I am currently doing clincals on the surgical specialty unit, and my patient is really at risk for hemorrhage at anytime. Unfortunetly there is no NANDA approved nursing diagnosis r/t this problem besides risk for injury. I don't like any of the interventions for this diagnosis. Does anyone have any other options that might be better for me?
Hi! Not sure what the exact situation is or why this pt is at risk for hemorrhage at any time. Hemorrhage being a collaborative problem, here are some inteventions you may like. They are aimed at bleeding precautions.
1. Monitor for signs and symptoms of persistant bleeding (eg check all secretions for frank or occult blood) to detect internal bleeding.
2. Monitor coagulation studies to determine bleeding risk.
3. Protect pt from trauma that may cause bleeding to reduce tissue trauma and subsequent bleeding into tissue.
4. Frequently monitor surgical site and dressings to detect any signs of bleeding.
5. Monitor vital signs regularly to detect any signs of hypovolemia.
6. Report abnormalities such as decreasing blood pressure; rapid pulse and resp.; cool, clammy skin; pallor and bright red blood on dressings.
7. Monitor for changes in mental status, such as restlessness and sense of impending doom as indicators of inadequate cerebral perfusion.
Maybe not much help but hopefully some!