- Deficient Knowledge related to misinformation and inadequate participation in care planning as evidenced by incorrect verbalization of the disease process and inadequate adherence to lab testing.
- Ineffective Protection related to low platelets and abnormal bleeding as evidenced by increased risk for bleeding altered clotting and prolonged bleeding time.
- Ineffective tissue perfusion related to Hypovolemia and bleeding disorders as evidenced by prolonged bleeding and cool and clammy skin
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: -Verbalizes poor understanding -Seeks additional information -Denial of a need to learn Objective Data: -Inaccurate demonstration or teach-back of instructions -Inability to recall instructions -Exhibiting aggression or irritability regarding teaching follow-up -Poor adherence to recommended treatment or worsening medical condition -Avoiding eye contact or remaining silent during teaching | Deficient Knowledge related to misinformation and inadequate participation in care planning as evidenced by incorrect verbalization of the disease process and inadequate adherence to lab testing | Patient will verbalize understanding of the disease process, prognosis, and treatment recommendations. Patient will implement two strategies to prevent bleeding. | 1. Educate the patient on bleeding precautions. Use caution with sharp objects Only use electric razors Brush the teeth gently Avoid aspirin-containing medications The patient should also not strain with bowel movements or insert anything rectally to prevent damaging the mucosal lining and causing internal bleeding. 2. Encourage lifestyle modifications. Lifestyle modifications, including avoidance of risk-taking behaviors such as dangerous sports that may lead to injury, can help lower the risk of bleeding complications. 3. Educate the patient about signs of possible thrombocytopenic complications. Early detection of signs and symptoms like easy bruising, sudden bleeding with unknown cause, blood in the urine or stool, bleeding in the gums and nose, and neurologic symptoms can indicate complications and progression of the disease. These signs and symptoms must be reported for prompt management. 4. Educate on the need for splenectomy. The removal of the spleen may be required for immune thrombocytopenia (ITP) or when other treatments have failed. The spleen plays a role in immune function, so the patient will need to take extra precautions to prevent infections. | -Patient verbalized that he/she understood the disease process, prognosis, and treatment recommendations. Patient implemented two strategies to prevent bleeding. |
| Subjective Data: -Verbalizes fear of bleeding Objective Data: -Low platelet count | Ineffective Protection related to low platelets and abnormal bleeding as evidenced by increased risk for bleeding altered clotting and prolonged bleeding time | Patient will demonstrate a platelet count within normal limits. Patient will not experience prolonged bleeding. Patient will implement strategies to prevent injury and bleeding | 1. Ensure safety. Emphasize the importance of safety. Implement safety precautions and fall prevention, as injuries can lead to excessive blood loss with thrombocytopenia. 2. Implement bleeding precautions. Advise the patient of the following: Avoid straining when defecating Blow the nose gently Use an electric razor Avoid rectal temperatures, enemas, or suppositories Use a soft-bristled toothbrush 3. Control the bleeding. For bleeding gums, apply pressure to the gums with gauze soaked in ice water. With nosebleeds, pinch the bridge of the nose and keep the head tilted forward until the bleeding stops. 4. Apply pressure after injections or IV site removal. After venipunctures, IM injections, or removal of IV lines, apply pressure for as long as necessary to stop bleeding, which may take 10-15 minutes | Patient demonstrated a platelet count within normal limits. Patient is not experiencing prolonged bleeding. Patient implemented strategies to prevent injury and bleeding |
Subjective Data: Chest Pain Dyspnea Sense of impending doom Objective Data: Arrhythmias Capillary refill >3 seconds Altered respiratory rate Use of accessory muscles to breathe Abnormal arterial blood gases | Ineffective tissue perfusion related to Hypovolemia and bleeding disorders as evidenced by prolonged bleeding and cool and clammy skin | Patient will demonstrate a platelet count > 150,000/mm³. Patient will not experience bleeding. Patient will demonstrate strong peripheral pulses with CRT < 3 seconds. | 1. Address the underlying condition. Manage the condition that is causing the low platelets. This may include discontinuing medications like heparin, treating infections or viruses, or managing autoimmune diseases. 2. Anticipate blood or platelet transfusions. Transfuse packed red blood cells (PRBC) or platelets as ordered. PRBC replaces blood lost from bleeding and aids in perfusing organs and tissues. At the same time, platelets supplement the low platelet count. 3. Prepare for a possible plasma exchange. Thrombotic thrombocytopenic purpura (TTP) causes clots to block blood flow to organs, preventing proper perfusion. Therapeutic plasma exchange (TPE) is a solution that replaces the plasma with a plasma substitute to prevent unnecessary clotting in the vessels. 4. Administer medications as ordered. The healthcare provider may choose medications to boost the platelet count if the condition affects the immune system. They may prescribe corticosteroids first. If ineffective, immunosuppressants can suppress the immune response. Other medications like eltrombopag or romiplostim are bone marrow stimulants that increase platelet counts. | -Patient bleeding stopped -Patient demonstrated strong peripheral pulses with CRT < 3 seconds. |