Chapter 11
Oncology: Nursing management in cancer care
251
Continues on following page
Nursing interventions
1. Assess for potential for bleeding:
monitor platelet count.
2. Assess for bleeding:
a. Petechiae or ecchymosis.
b. Decrease in haemoglobin or
haematocrit.
c. Prolonged bleeding from invasive
procedures, venipunctures, minor
cuts or scratches.
d. Frank or occult blood in any body
excretion, emesis, sputum.
e. Bleeding from any body orifice.
f. Altered mental status.
3. Instruct patient and family about ways
to minimise bleeding:
a. Use soft toothbrush for mouth care.
b. Avoid commercial mouthwashes.
c. Use electric razor for shaving.
d. Use emery board for nail care.
e. Avoid foods that are difficult to
chew.
4. Initiate measures to minimise
bleeding.
a. Draw all blood for lab work with
one daily venipuncture.
b. Avoid taking temperature rectally
or administering suppositories and
enemas.
c. Avoid intramuscular injections; use
smallest needle possible.
d. Apply direct pressure to injection
and venipuncture sites for at least
5 min.
e. Lubricate lips with petroleum jelly.
f. Avoid bladder catheterisations; use
smallest catheter if catheterisation
is necessary.
g. Maintain fluid intake of at least
3 L/24 hours unless contraindicated.
h. Use stool softeners or increase bulk
in diet.
i. Avoid medications that will interfere
with clotting (e.g. aspirin).
j. Recommend use of water-based
lubricant before sexual intercourse.
5. When platelet count is less than
20 × 10
9
/L, institute the following:
Rationale
1. Mild risk:
.
50 × 10
9
/L
Moderate risk: 20–50 × 10
9
/L
Severe risk:
,
20 × 10
9
/L
2. Early detection promotes early
intervention.
a. Indicates injury to microcirculation
and larger vessels.
b–e. Indicates blood loss.
f. Indicates neurological involvement.
3. Patient can participate in self-
protection.
a. Prevents trauma to oral tissues.
b. Contain high alcohol content that
will dry oral tissues.
c. Prevents trauma to skin.
d. Reduces risk of trauma to nail beds.
e. Prevents oral tissue trauma.
4. Preserves circulating blood volume.
a. Minimises trauma and blood loss.
b. Prevents trauma to rectal mucosa.
c. Prevents intramuscular bleeding.
d. Minimises blood loss.
e. Prevents skin from drying.
f. Prevents trauma to urethra.
g. Hydration helps to prevent skin
drying.
h. Prevents constipation and straining
that may injure rectal tissue.
i. Minimises risk of bleeding.
j. Prevents friction and tissue trauma.
5. Platelet count of less than 20 × 10
9
/L
is associated with increased risk of
spontaneous bleeding.
Expected outcomes
• Signs and symptoms of bleeding are
identified.
• Exhibits no blood in faeces, urine or
emesis.
• Exhibits no bleeding of gums or of
injection or venipuncture sites.
• Exhibits no ecchymosis (bruising).
• Patient and family identify ways to
prevent bleeding.
• Uses recommended measures to
reduce risk of bleeding (uses soft
toothbrush, shaves with electric
razor only).
• Exhibits normal vital signs.
• Reports that environmental hazards
have been reduced or removed.
• Consumes adequate fluid.
• Reports absence of constipation.
• Avoids substances interfering with
clotting.
• Absence of tissue destruction.
• Exhibits normal mental status and
absence of signs of intracranial
bleeding.
• Avoids medications that interfere
with clotting (e.g. aspirin).
• Absence of epistaxis and cerebral
bleeding.
Plan of Nurs ing Care
Care of patient with cancer
(
continued
)
Collaborative problem:
Potential complication: risk of bleeding problems
Goal:
Prevention of bleeding
CHART
11-4
