Nursing Care Plan Patient with Thrombocytopenia

Nursing Care Plan Nursing Care Plan Patient with Thrombocytopenia Nursing Diagnosis* Impaired Oral Mucous Membranes Etiology: Low platelet counts, effects of pathologic conditions and treatment Supporting data: Gingival bleeding, oral lesions Patient Goal Maintains lesion-free oral mucosa without bleeding Outcomes (NOC) Oral Health  Bleeding ___  Oral mucosa lesions ___ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None Interventions (NIC) and Rationales Oral Health Restoration  Monitor condition of patient’s mouth (e.g., lips, tongue, mucous membranes, teeth, and gums) including character of abnormalities (e.g., size, color, and location of internal or external lesions or inflammation, and other signs of infection) to provide information for planning interventions.  Encourage avoidance of spicy, salty, acidic, dry, rough, or hard foods to decrease irritation of oral mucosa.  Teach patient to use soft-bristled toothbrush or disposable mouth sponge to remove dental debris while preventing irritation of oral mucosa.  Teach patient, caregiver(s), or family member(s) on frequency and quality of proper oral health care to avoid breakdown of oral mucosa.  Teach patient to avoid oral hygiene products containing glycerin, alcohol, or other drying agents to prevent excessive drying of the mucosa. Nursing Diagnosis Risk for Bleeding Risk factors: Decreased platelets, treatment-related side effects, inherent coagulopathies Patient Goals 1. Maintains tissue integrity 2. Has no evidence of bleeding or bruising Outcomes (NOC) Blood Coagulation  Bleeding ___ Interventions (NIC) and Rationales Bleeding Precautions  Monitor for signs and symptoms of persistent *Nursing diagnoses listed in order of priority. eNursing Care Plan Outcomes (NOC)  Bruising ___  Petechiae ___  Ecchymosis ___  Purpura ___  Hematuria ___  Hemoptysis ___ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None Interventions (NIC) and Rationales bleeding (i.e., check all secretions for frank or occult blood) to detect internal bleeding.  Monitor coagulation studies, including prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen, fibrin degradation/split products, and platelet counts, to determine bleeding risk.  Avoid injections (IV, IM, subcutaneous) to prevent bleeding into tissue surrounding puncture site.  Have patient use electric razor instead of straightedge razor blade for shaving to reduce potential for skin nicks.  Protect patient from trauma to reduce tissue damage and subsequent bleeding into tissue.  Administer blood products (e.g., platelets, fresh frozen plasma) to replace coagulation factors.  Tell patient to avoid invasive procedures; if they are necessary, monitor closely for bleeding, to reduce potential for internal bleeding.  Teach patient and/or caregiver(s) to avoid aspirin or other anticoagulants to prevent additional bleeding risk. Nursing Diagnosis Lack of Knowledge Etiology: Lack of information about the disease process, activity, and medication Supporting data: Questions about disease management, anxiety, restlessness Patient Goal States required knowledge and skills to manage disease process at home Outcomes (NOC) Knowledge: Disease Process  Characteristics of specific disease ___  Cause and contributing factors ___  Signs and symptoms of disease ___  Usual course of disease process ___  Signs and symptoms of disease complications ___  Benefits of disease management ___ Interventions (NIC) and Rationales Teaching: Disease Process  Assess patient’s current level of knowledge related to specific disease process to plan appropriate interventions.  Describe disease process.  Describe common signs and symptoms of the disease so patient will know what to expect.  Discuss treatment/therapy options to decrease anxiety and prevent complications.  Discuss lifestyle changes that may be required to prevent future complications and/or control the disease process so patient will be informed and able to manage self-care or direct others in care. eNursing Care Plan Outcomes (NOC) Measurement Scale 1 = No knowledge 2 = Limited knowledge 3 = Moderate knowledge 4 = Substantial knowledge 5 = Extensive knowledge Interventions (NIC) and Rationales  Refer patient to local community agencies/support groups for continued education and support.  Provide the phone numbers to call if complications occur to enable control of complications.