B
Risk for Bleeding
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Discuss precautions to prevent bleeding complications
• Explain actions that should be taken if bleeding happens
• Maintain adherence to agreed upon anticoagulant medication and lab work regimens
• Monitor for signs and symptoms of bleeding
• Maintain a mean arterial pressure above 70 mm Hg, a heart rate between 60 and 100 with a normal rhythm, and urine output greater than 0.5 mL/kg/hr
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Perform admission risk assessment for falls and for signs of bleeding. Safety precautions should be implemented for all at risk patients. EBN: Upon admission to any health care facility nurses should assess for fall risk factors that could increase the risk of bleeding (Gray-Micelli, 2008; Holmes, 2011).
• Monitor the client closely for hemorrhage especially in those at increased risk for bleeding. Watch for any signs of bleeding including: bleeding of the gums, blood in sputum, emesis, urine or stool, bleeding from a wound, bleeding into the skin with petechiae, and purpura. EB: Clients at increased risk for bleeding may include older individuals (>60 years of age), individuals with active gastroduodenal ulcer, postpartum women, previous bleeding episode, hypertension, labile INRs, low platelet count, active malignancy, renal or liver failure, ICU stay, drug or alcohol use, co-administered antiplatelets with nonsteroidal antiinflammatory drugs, clients receiving antithrombotic and anticoagulant therapies (Chen et al, 2011; Chua et al, 2011; Decousus et al, 2011). Additional relevant research: Gupta et al, 2010; Hochholzer et al, 2011; Lane et al, 2011; Pisters et al, 2010; Tay, Lip & Lane, 2011. Individuals who take selective serotonin reuptake inhibitors (SSRIs) with or without a history of gastrointestinal bleeding may be at increased risk for bleeding especially if concurrently taking NSAIDs or low-dose aspirin (Andrade et al, 2010). Use of aspirin and clopidogrel in the treatment of clients with image verified “small” subcortical strokes demonstrated higher rates of bleeding when compared to treatment with aspirin alone (Stiles, 2011).
• If bleeding develops, apply pressure over the site as needed or appropriate, on the appropriate pressure site over an artery, and use pressure dressings as needed (Matteucci, Schub, & Pravikoff, 2011).
Monitor coagulation studies, including prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (aPTT), fibrinogen, fibrin degradation/split products, and platelet counts as appropriate. EB: INR is the preferred method to evaluate warfarin therapy, typically at least 16 hours after the last dose is administered. Dose adjustments will not result in a steady-state INR value for up to 3 weeks (ICSI, 2011).The aPTT is most commonly used to assess unfractionated heparin (UH) therapy but some clients may require additional testing to assess for heparin resistance (Russo, 2010). Replacement of UH with low molecular weight heparin and other new anticoagulants may be forthcoming but UH is still a drug of choice due to ability to rapidly reverse effect with protamine sulfate (Lehman & Frank, 2009).
Assess vital signs at frequent intervals to assess for physiological evidence of bleeding such as tachycardia, tachypnea, and hypotension. Symptoms may include dizziness, shortness of breath, and fatigue. Carefully assess for compensatory changes associated with bleeding including increased heart rate and respiratory rate. Initially blood pressure may be stabile and then begin to decrease. Assess for orthostatic blood pressure changes (drop in systolic by >20 mm Hg and/or a drop in diastolic by >10 mm Hg in 3 minutes) by taking the blood pressure in lying, sitting, and standing positions (Matteucci, Schub, & Pravikoff, 2011; Urden, Stacy, & Lough, 2009). Prospective identification of clients at risk for massive transfusion is an imprecise science (Vandromme et al, 2011).
Monitor all medications for the potential to increase bleeding including aspirin, NSAIDs, SSRIs, and complementary and alternative therapies such as coenzyme Q (10) and ginger. CEB: Antiplatelet medications can increase the risk of bleeding in high-risk clients (ICSI, 2011). In a study of adults receiving warfarin, CoQ (10) and ginger appeared to increase the risk of bleeding (Shalansky et al, 2007). Ginger, when taken with medicines that slow clotting, may increase the chances for bruising and bleeding (Medline Plus, 2011). Aspirin use has been shown to reduce myocardial infarcts in men, and women receiving aspirin experienced fewer ischemic strokes; however, aspirin does increase the risk for major bleeding events, primarily those of gastrointestinal origin (Wolff, Miller, & Ko, 2009).
Safety Guidelines for Anticoagulant Administration: Joint Commission National Patient Safety Goals 2011: Follow approved protocol for anticoagulant administration:
• Use prepackaged medications and prefilled or premixed parenteral therapy as ordered
• Check laboratory tests (i.e., INR) before administration
• Use programmable pumps when using parenteral administration
• Ensure appropriate education for client/family and all staff concerning anticoagulants used
• Notify dietary services when warfarin prescribed (to reduce vitamin K in diet)
• Monitor for any symptoms of bleeding prior to administration. Standard defined protocols can decrease errors in administration (Joint Commission, 2011). Anticoagulation therapy is complex. Risk of bleeding is reduced in clients who receive appropriate education in anticoagulant therapy use (Metlay et al, 2008).
Before administering anticoagulants, assess the clotting profile of the client. If the client is on warfarin, assess the INR. Hold the medication if the INR is outside of the recommended parameters and notify the physician or advanced practice nurse. EB: Target INR for warfarin is between 2.0 and 3.0 for nonvalvular atrial fibrillation and between 2.5 and 3.5 for valvular atrial fibrillation. Risk of bleeding is increased when INR is >4.0 and risk for thromboembolism increases when INR is <1.7. A 2% to 4% risk for bleeding remains in individuals within therapeutic range of INR. Dose adjustments of 15% usually change the INR level by 1.0 (ICSI, 2011). A safety advisory was issued by the Australian regulatory authority for the anticoagulant dabigatran (Pradaxa) due to an increase in the number of bleeding-related adverse events (Hughes, 2011).
Recognize that vitamin K may be given orally or intravenously as ordered for INR levels greater than 5.0. In some circumstances fresh frozen plasma (FFP), prothrombin complex concentrate (PCC), and/or recombinant factor VIIa (rVIIa) may be administered if serious or life-threatening bleeding occurs. EB: With INR levels above 5.0 it is recommended to give vitamin K rather than just holding the warfarin; administration of vitamin K is through the oral or intravenous route as subcutaneous or intramuscular routes result in erratic absorption (ICSI, 2011).
Consider discussing the co-administration of a proton-pump inhibitor alongside traditional NSAIDs, or with the use of a cyclo-oxygenase 2 inhibitor with the prescriber. EB: Risk of NSAID-related bleeding may be reduced with the use of a proton-pump inhibitor or cyclo-oxygenase 2 inhibitor (Chua et al, 2011; Rahme & Bernatsky, 2011; Wu et al, 2011).
• Ensure adequate nurse staffing in order to be able to provide a high level of surveillance capability. CEB: The size and mix of nurse staffing in hospitals has been demonstrated to have a direct impact on client outcomes. Lower levels of nurse staffing have been associated with higher rates of poor client outcomes including those outcomes caused by gastrointestinal bleeding and “failure to rescue” (Needleman et al, 2002).
Pediatric:
Recognize that prophylactic vitamin K administration should be used in neonates for vitamin K deficiency bleeding (VKDB). CEB: Hemorrhagic disease of the newborn (HDN) is due to vitamin K deficiency resulting in life-threatening bleeding within the first hours of life (Clarke et al, 2006). A single oral or parenteral administration of vitamin K prevents early VKDB (birth to 2 weeks of age) in contrast to late VKDB (2-12 weeks of age) that is prevented by parenteral administration (Miller, 2003).
Recognize warning signs of VKDB including minimal bleeds, evidence of cholestasis (icteric sclera, dark urine, irritability), and failure to thrive. CEB: Warning signs are often present but may be overlooked (Sutor, 2003).
Use caution in administering NSAIDs in children. EB: A study of children aged 2 months to 16 years found that although upper gastrointestinal bleeding is rare, one third of the cases seen were attributable to exposure to NSAID at doses used for analgesia or antipyretic purposes (Grimaldi-Bensouda et al, 2010).
Monitor children and adolescents for potential bleeding. EB: Children and adolescents who take SSRIs need to be closely monitored as the potential for bleeding exists across age groups (Andrade et al, 2010).
Closely monitor post-cardiotomy clients requiring extracorporeal life support when cardiopulmonary bypass (CPB) duration is prolonged. EB: In a retrospective study of clients excessive bleeding was found to occur more frequently in children who had been on CPB for more than 3 hours (Nardell et al, 2009). Excessive bleeding occurred predominantly within 6 hours postoperatively. Incidence of bleeding increased when the client had lower platelet counts (Nardell et al, 2009).
Client/Family Teaching and Discharge Planning:
• Teach client and family or significant others about any anticoagulant medications prescribed including when to take, how often to have lab tests done, signs of bleeding to report, dietary restrictions needed, and precautions to be followed. Instruct the client to report any adverse side effects to his/her health care provider. Medication teaching includes the drug name, purpose, administration instructions (e.g., with or without food), necessary lab tests, and any side effects to be aware of. Provision of such information using clear communication principles and an understanding of the client’s health literacy level may facilitate appropriate adherence to the therapeutic regimen by enhancing knowledge base (Joint Commission, 2011; National Institutes of Health (NIH), 2011; Nurit et al, 2009). EB: Education of the client reduces the risk of bleeding (Metlay et al, 2008).
• Instruct the client and family on disease process and rationale for care. When clients and their family members have sufficient understanding of their disease process they can participate more fully in care and healthy behaviors. Knowledge empowers clients and family members allowing them to be active participants in their care. EBN: Use of written and verbal education enhances client retention of information needed when managing potent medications (Nurit et al, 2009).
• Provide client and family or significant others with both oral and written educational materials that meet the standards of client education and health literacy. EB: The use of clear communication, materials written at a fifth grade level, and the teach-back method enhances the client’s ability to understand important health related information and improves self-care safety (NIH, 2011).
References
Alderson, P., et al, The Albumin Reviewers Human albumin solution for resuscitation and volume expansion in critically ill patients. Cochrane Database Syst 2004;(4):CD001208.
Andrade, C., et al. Serotonin reuptake inhibitor antidepressants and abnormal bleeding: a review for clinicians and a reconsideration of mechanisms. J Clin Psychiatry. 2010;71(12):1565–1575.
Chen, W., et al. Association between CHADS2 risk factors and anticoagulation-related bleeding: a systematic literature review. Mayo Clin Proc. 2011;86(6):509–521.
Chua, S., et al. Gastrointestinal bleeding and outcomes after percutaneous coronary intervention for ST-segment elevation myocardial infarction. Am J Crit Care. 2011;20(3):218–225.
Clarke, P., et al. Vitamin K prophylaxis for preterm infants: a randomized controlled trial of 3 regimens. Pediatrics. 2006;118:e1657–e1666.
Decousus, H., et al. Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators. Chest. 2011;139(1):69–79.
Gray-Micelli, D. Preventing falls in acute care. In Capezuti E, et al, eds.: Evidence-based geriatric nursing protocols for best practice, ed 3, New York: Springer, 2008.
Grimaldi-Bensouda, L., et al. Clinical features and risk factors for upper gastrointestinal bleeding in children: a case-crossover study. Eur J Clin Pharmacol. 2010;66(8):831–837.
Gupta, N., et al. Defining patients at high risk for gastrointestinal hemorrhage after drug-eluting stent placement: a cost utility analysis. J Interv Cardiol. 2010;23(2):179–187.
Hochholzer, W., et al. Predictors of bleeding and time dependence of association of bleeding with mortality: insights from the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction 38 (TRITON-TIMI 38). Circulation. 2011;123(23):2681–2689.
Holmes, S. Risk for bleeding. In Ackley B., Ladwig G., eds.: Nursing diagnosis handbook, ed 9, St Louis: Mosby, 2011.
Hughes, S. Dabigatran: Australia issues bleeding warning, Heartwire. Retrieved October 9, 2011;2011;10, from http://www.medscape.com/viewarticle/751161_print
Institute for Clinical Systems Improvement (ICSI). Antithrombotic therapy supplement. Bloomington, MN: ICSI; 2011.
Joint Commission, Hospital national patient safety goals—effective July 1, 2011 Retrieved October 10, 2011, from http://www.jointcommission.org/hap_2011_npsgs/
Lane, D., et al. Bleeding risk in patients with atrial fibrillation: the AMADEUS study. Chest. 2011;140(1):146–155.
Lehman, C., Frank, E. Laboratory monitoring of heparin therapy: partial thromboplastin time or anti-Xa assay? Labmed. 2009;40(1):47–51.
Matteucci, R., Schub, T., Pravikoff, D. Shock, hypovolemic. In: CINAHL nursing guide. Nursing Reference Center; 2011.
Medline Plus, Ginger. MedLine Plus 2011;11, Accessed November 11, 2011 http://www.nlm.nih.gov/medlineplus/druginfo/natural/961.html
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Miller, C. Controversies concerning vitamin K and the newborn: policy statement of the American Academy of Pediatrics. Pediatrics. 2003;112(1):191–192.
Nardell, K., et al. Risk factors for bleeding in pediatric post-cardiotomy patients requiring ECLS. Perfusion. 2009;24(3):191–197.
National Institutes of Health, Clear communication: An NIH health literacy initiative, 2012 Retrieved August 3, 2012, from http://www.nih.gov/clearcommunication/plainlanguage.htm
Needleman, J., et al. Nurse staffing and quality of care in hospitals in the United States. Policy Polit Nurs Pract. 2002;3(40):306–308.
Nurit, P., et al. Evaluation of a nursing intervention project to promote patient medication education. J Clin Nurs. 2009;18(17):2530–2536.
Pisters, R., et al. A novel user friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro heart study. Chest. 2010;138:1093–1100.
Rahme, E., Bernatsky, S. NSAIDs and risk of lower gastrointestinal bleeding. Lancet. 2011;376:7.
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Shalansky, S., et al. Risk of warfarin-related bleeding events and supratherapeutic international normalized ratios associated with complementary and alternative medicine: a longitudinal analysis. Pharmacotherapy. 2007;27(9):1237–1247.
Stiles, S., Clopidogrel-aspirin arm halted in SPS3 stroke trial. Heartwire 2011;10, Retrieved October 7, 2011, from http://www.medscape.com/viewarticle/751011_print
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Wu, H., et al. Pantoprazole for the prevention of gastrointestinal bleeding in high-risk patients with acute coronary syndromes. J Crit Care. 26(4), 2011. [434.e1-6].
Disturbed Body Image
NANDA-I
Defining Characteristics
Behaviors of acknowledgment of one’s body; behaviors of avoidance of one’s body; behaviors of monitoring one’s body; nonverbal response to actual change in body (e.g., appearance, structure, function); nonverbal response to perceived change in body (e.g., appearance, structure, function); reports feelings that reflect an altered view of one’s body (e.g., appearance, structure, function); reports perceptions that reflect an altered view of one’s body in appearance
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Demonstrate adaptation to changes in physical appearance or body function as evidenced by adjustment to lifestyle change
• Identify and change irrational beliefs and expectations regarding body size or function
• Recognize health-destructive behaviors and demonstrate willingness to adhere to treatments or methods that will promote health
• Verbalize congruence between body reality and body perception
• Describe, touch, or observe affected body part
• Demonstrate social involvement rather than avoidance and utilize adaptive coping and/or social skills
• Utilize cognitive strategies or other coping skills to improve perception of body image and enhance functioning
• Utilize strategies to enhance appearance (e.g., wig, clothing)
NIC (Nursing Interventions Classification)
Body Image Enhancement, Eating Disorder Management, Referral, Self-Awareness Enhancement, Self-Esteem Enhancement, Support Group Weight Gain Assistance
Nursing Interventions and Rationales
• Incorporate psychosocial questions related to body image as part of nursing assessment to identify clients at risk for body image disturbance (e.g., body builders; cancer survivors; clients with eating disorders, burns, skin disorders, polycystic ovary disease; or those with stomas/ostomies/colostomies or other disfiguring conditions). EB: Assessment of psychosocial issues can help to identify clients at risk for body image concerns as a result of a disfiguring condition (Borwell, 2009). Nurses, caring for patients during their hospital stay, are in the ideal position to assess how they are emotionally adapting to having a disfigurement (Bowers, 2008).
• If client is at risk for body image disturbance, consider using a tool such as the Body Image Quality of Life Inventory (BIQLI) or Body Areas Satisfaction Scale (BASS), which quantifies both the positive and negative effects of body image on one’s psychosocial quality of life. EBN: Using a body image scale can help nurses to identify possible body image disturbances and to plan individual nursing interventions (Giovannelli et al, 2008).
Assess for history of childhood maltreatment in clients suffering from body dissatisfaction, anorexia, or other eating disorders and make appropriate psychosocial referrals if indicated. EB: The results from this study indicate specific forms of childhood maltreatment (emotional and sexual abuse) are significantly associated with body dissatisfaction, depressive symptoms, and eating disorders (Dunkley et al, 2010).
Assess for body dysmorphic disorder (BDD) (pathological preoccupation with muscularity and leanness; occurs more often in males than in females) and refer to psychiatry or other appropriate provider. EB: Body dysmorphic disorder (BDD) is a prevalent and disabling preoccupation with a slight or imagined defect in appearance. Results from the small number of available randomized controlled trials (RCTs) suggest that serotonin reuptake inhibitors (SRIs) and cognitive behavioral therapy (CBT) may be useful in treating clients with BDD (Ipser, Sander, & Stein, 2009).
Assess for steroid use, if BDD is identified. EB: The current evidence from this literature review suggests that anabolic androgenic steroid (AAS) abuse is possibly a perpetuating factor in the evolution of muscle dysmorphia (MD). Psychiatric complications of AAS include mood and behavior changes, perceptual abnormalities, and withdrawal symptoms (Rohman, 2009).
• Assess for lipodystrophy (an abnormal redistribution of adipose tissue) in clients receiving antiretroviral therapy as a treatment for HIV/AIDS. This condition is common and can be a source of distress to clients. EBN: Lipodystrophy is often an unavoidable side effect of antiretroviral therapy. Clients suffering from this syndrome are often ignored when expressing concerns about body changes. Nurses are uniquely qualified to assess these clients as well as provide education and psychosocial support (Gagnon & Holmes, 2011).
If client is at risk for anorexia nervosa, consider investigation of emotional qualifiers, using a tool to assess emotional intelligence such as the EQ-1. EB: A study of female university students ages 18 to 30 found a significant correlation between disordered eating behaviors and lower levels of emotional intelligence, particularly in the areas of emotional self-awareness, interpersonal relationships, stress management, and happiness (Costarelli, Demerzi, & Stamou, 2009).
• Discuss expectations for weight loss and anticipated body changes with clients planning to undergo bariatric surgery for morbid obesity. Assist the client in identifying realistic goals. EB: Morbidly obese clients often set unrealistic goals for ideal body weight and appearance following bariatric surgery. Guidance is necessary to help them understand limitations of the surgery (Munoz et al, 2010).
Use cognitive-behavioral therapy (CBT) to assist the client to express his emotions and feelings. EBN: This study of clients with bulimia used CBT and helped the clients to disentangle themselves regarding body image and weight (Huang & Hsieh, 2010).
• Help client describe ideal self, identify self-criticisms, and give suggestions to support acceptance of self. EBN: Job rehabilitation and body image should be incorporated into the daily care of head and neck cancer clients. For example, participants could learn how to use cosmetic strategies to improve their facial appearance during otopalatodigital (OPD) syndrome follow-up. Thus, the negative impact might be reduced (Liu, 2008).
• Discuss spirituality as an adjunct to improving body satisfaction. EB: Qualitative data reported improvements in body satisfaction and lower occurrences of disordered eating associated with the practice of yoga and its related spirituality (Dittmann & Freedman, 2009).
• Provide education and support for clients receiving treatments or medications that have the potential to alter body image. Discuss alternatives if available. EBN: Men receiving androgen-deprivation therapy as a treatment for prostate cancer may be at greater risk of body image dissatisfaction (Harrington, Jones, & Badger, 2009).
• Encourage the clients to write a narrative description of their changes. EBN: Expressive writing has therapeutic benefits with feelings of greater psychological well-being and fewer posttraumatic intrusion and avoidance symptoms (Atkinson et al, 2009).
• Take cues from clients regarding readiness to look at wound (may ask if client has seen wound yet) and utilize clients’ questions or comments as way to teach about wound care and healing. CEB: Tailoring interventions to individual clients and reading their nonverbal cues likely contributes to clients’ ability to heal emotionally from impact of wound on body image (Birdsall & Weinberg, 2001).
Encourage client to participate in regular aerobic and/or non-aerobic exercise when feasible. EB: Participants of this study demonstrated higher levels of body satisfaction following the very first exercise session (Vocks et al, 2009).
Provide client with a list of appropriate community support groups (e.g., Reach to Recovery, Ostomy Association). EB: This study of three different cancer groups (a group for women with metastatic cancer, a colorectal cancer support group, and a group for Chinese cancer patients) showed their perceived benefits were similar; the groups provided information, acceptance, and understanding (Bell et al, 2010).
Pediatric: Note: Many of the above interventions are appropriate for the pediatric client.
Refer parents of children with eating disorders to a support group. EB: Parents indicated that it assisted them in understanding eating disorder symptoms and treatment and supporting their child struggling with an eating disorder. Additionally, the group was a source of emotional support. Results suggest that inclusion of a parent support group in the outpatient treatment of children and adolescents with eating disorders has important implications for parents (Pasold, Boateng, & Portilla, 2010).
Refer children and families with severe facial burns for psychosocial support. EB: Severe facial burn influences health-related quality of life (HRQOL) in children. Additional psychosocial support is suggested to enhance recovery for patients with severe face burns and their families during the years following injury (Stubbs et al, 2011).
Assess family dynamics and refer parents of adolescents with anorexia or other eating disorders to professional family counseling if indicated. EB: This study indicated that when adolescents’ basic psychological needs are met, they are less likely to worry about the adequacy of body appearance and engage in unhealthy weight control behaviors. Parenting practices such as lack of emotional support or demanding conformity have negative impacts on adolescents suffering from eating disorders (Thøgersen-Ntoumani, Ntoumanis, & Mikitaras, 2010).
• Discuss with parents the potentially negative influence media has on younger children as a source of unrealistic ideals of body image. EB: Results of this study suggest that more frequent viewing of programming such as music videos and soap operas promotes higher levels of body dissatisfaction and restrained eating in young girls (Anschutz, et al, 2009).
Consider using a measurement tool such as the Children’s Body Image Scale (CBIS) if a child is at risk for body image disturbance. EB: The CBIS has produced stable results for measurements of children’s body size perception and satisfaction (Truby & Paxton, 2008).
Geriatric:• Focus on remaining abilities. Have client make a list of strengths. CEB: Results from unstructured interviews with women aged 61 to 92 years regarding their perceptions and feelings about their aging bodies suggest that women exhibit the internalization of ageist beauty norms, even as they assert that health is more important to them than physical attractiveness and comment on the “naturalness” of the aging process (Hurd, 2000).
• Encourage regular exercise for the elderly. EBN: This study of 85-year-olds in Sweden emphasized the importance of activities and exercises in staying fit and having a good quality of life and better perceived health (Fischer et al, 2008).
Multicultural:• Assess for the influence of cultural beliefs, regional norms, and values on the client’s body image. EB: A study of young adults living in Hawaii and Australia demonstrated a tolerance for body sizes that are significantly larger than the size (BMI) considered healthy (Knight, Latner, & Illingworth, 2010). EBN: Each client should be assessed for body image based on the phenomenon of communication, time, space, social organization, environmental control, and biological variations (Giger & Davidhizar, 2008). EB: A study of Muslim women found that the strength of their religious faith was inversely related to body dissatisfaction (Mussap, 2009).
• Acknowledge that body image disturbances can affect all individuals regardless of culture, race, or ethnicity. EB: Results in this study suggest that gender and cultural differences in body image among adolescents are significant (Ceballos & Czyzewska, 2010). Body image disorders are becoming increasingly prevalent in developing non-Western countries such as China (Xu et al, 2010).
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