Textbook of Medical-Surgical Nursing 3e

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Chapter 11

Oncology: Nursing management in cancer care

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

Rationale 1. Mild risk: . 50 × 10 9 /L

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.

Nursing interventions 1. Assess for potential for bleeding: monitor platelet count.

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.

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:

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.

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