Kapiolani Community College

Associate Degree Nursing Program

Nurs320 Nursing Care Plan
Student Name Felicia Vaifale

Date of Care: 00/00/0000

Date Submitted: 00/00/0000

Nursing Diagnosis: coagulating deficiency-bleeding d/t thrombocytopenia

Related to: s/p chemotherapy, transmitted platelet deficiency coagulopathies, abnormal hepatic/renal function

As manifested by: petechiae, labs with decreased platelet (9),

Scientific Rationale: Thrombocytopenia is a condition in which a person's blood has an unusually low level of platelets. Platelets,
also called thrombocytes, are found in a person's blood. They stop bleeding by helping the blood to clot and plugging
damaged blood vessels. Thrombocytopenia happens when the body does not make enough platelets, is losing platelets, or
destroys platelets. Thrombocytopenia is common in people with cancer, especially in those receiving chemotherapy.
Cancer.net/thrombocytopenia retrieved on 10//4/15

Outcomes (measurable)

Short Term

Interventions

Rationale

Evaluation

1. Monitor platelet counts, anticipate

the platelet count nadir.

1.

1. Platelet count 9,000, this patient is

at a severe risk for bleeding

Patient will be able to adhere to safety

precautions (compliance with preventive
measures) r/t increased bleeding.

Long Term
Patient will have reduced risk for

2. Monitor coagulation parameters

(fibrinogen, thrombin time, bleeding
time, fibrin degradation products) if
indicated

The risk for bleeding increases as

the platelet count drops: Nadir is
when platelets are at their lowest
point.
- Less than 20,00/mm=
severe risk
- 20,000-50,000 = moderate
risk
- 50,000-100,000= mild risk;
does not usually require
treatment
- Greater than 100,000= no

bleeding, as evidenced by platelets

within acceptable limits, and prompt
reporting of early signs and symptoms

2.

3. Evaluate for any medications that

interfere with hemostasis
(salicylates, anticoagulants,
nonsteroidal anti-inflammatory
drugs)

3.
4.

4. Assess the patient regularly for

evidence of the following
-spontaneous petechiae (all skin
surfaces, including oral mucosa)
-Prolonged bleeding or new areas
of ecchymoses or hematoma from
invasive procedures (venipuncture,
injection, and bone marrow site)
-oozing of blood from nose or gums
-rectal bleedings

5.

6.

7.

-neurological status
8.
5. If any significant bleeding occurs,
monitor vial signs closely until the
bleeding in controlled

6. Instruct the patient of significant

9.

significant risk
The blood clotting cascade is an
integrated system requiring inrinsic
and extrinsic factors.
Derangements in any factors cn
affect clotting ablility. These lab
tests provid important information
on clotting ability and bleeding
potential
Drugs that interfere with clotting
mechanisms or platelet activity
increase the risk for bleeding
Changes in the coagulation profile
be marked by ecchymosis,
hematomas, petechiae, blood in
body excretions, bleeding from
body orifices, and a change in
neurological status (including
headache, visual disturbances, o
change in level of consciousness)
Sinus tachycardia and increased
arterial BP are seen in the early
stages to maintain an adequate
cardiac output. Blood pressure
drops as the condition deteriorates.
Most individuals are not familiar
with the complexities of the
hematological system. A successful
treatment plan requires the
knowledge and cooperation of the
patient and family members
An understanding of precautionary
measures reduces the risk for
bleeding. At platelet counts less
than 50,000/mm spontaneous
bleeding can occur.
Their use increases the chance of
rectal bleeding
It is important to have platelets
available when needed. (when
platelets are less than 10,000/mm
or in the presence of active
bleeding) Platelet thresholds need
to be inividulaized. Prophylactic

2. Continue to monitor relevant labs

3. Ranitidine has a SE of
thrombocytopenia-re-evaluation
needed

4. Patient does have petechiae

present throughout hospital stay, no
increase/changes to skin, no signs
of active bleeding noted. (old
suction set had old blood-changed
out set and no further signs of
bleeding. BM brown, soft. Mucosa
membrane with lesions/sores
present no bleeding noted.

5. VSS afebrile, no s/s of significant

bleeding
6. Per patient, he knows that the
sores, and decreased platelets are
SE of his CHEMO treatment
7. Teaching to the patient was done, in
depth understanding and grasp of

others of the effects of

chemotherapy on bone marrow
function and platelet count, and the
relationship between platelets and
bleeding.
7. Implement bleeding precautions for
a platelet count of less than
50,000/mm

platelet transfusions may be

administered

the severity of his bleeding risk was

unsure- did not want to overwhelm
the patient
8. Nothing to rectal area
9. Platelet transfusion done (multiple)
per physician he is a difficult case
continue with safety and prevention

8. Rectal thermometers, suppositories,

and enemas
9. Communicate the anticipated need
for platelet support to a transfusion
center. Transfuse single or random
donor platelets, as ordered
Reference: Ball, J., Bindler, R., & Cowen, K. (2012). Principles of pediatric nursing: Caring for children (5th ed.). Boston: Pearson
Gulanick, M., & Myers, J. L. (2014). Nursing care plans: Diagnoses, interventions, and outcomes. (8th ed.).
Philadelphia, PA: Elsevier.