CLIENTS NURSING CARE PLAN FORM

Student: Brandi Rambeau

Client Initials: G.P.
Age: 67 Medical Diagnosis: Hemoptysis and Anemia
Nursing Diagnostic Statement

2.Risk for bleeding r/t irritation

of airway secondary to
laryngeal mass, anticoagulation
therapy, and iron deficiency
secondary to anemia.
-

Rationale for Nursing Diagnosis

Literature-based Rationale for Nursing Diagnosis Client Situation Rationale for Nursing Diagnosis

The principle complication of

anticoagulant therapy is spontaneous
bleeding anywhere in the body. (Day et
al., 2007, p. 848).
The most common and potentially
devastating complication of
warfarin therapy is haemorrhage.
An INR>4.0 places the patient at a
greater risk of a bleed. Older patients
who incur an episode of
overanticoagulation take longer to
return to a safe level, exposing them to
potential bleeding complications.
Poor control of Warfarin may lead
to increased morbidity and mortality,
frequent doctor visits, longer
and more frequent hospital stays
and resultant increased health and
hospital costs. (Westaway, Cruickshank,
Roberts, & Esterman, 2010).
Anemia is a condition in which the
hemoglobin content of the blood is
insufficient to satisfy bodily demands.
The condition usually is due to a decrease
in the number of circulating RBCs
(Lemone & Burke, 2000 p. 1268).
Treatment of the client with anemia is
directed toward ensuring adequate tissue
oxygenation. Common treatments for
clients with anemia include
pharmacologic therapy, dietary

G.P. is a 67 year old male who came to

the hospital via EHS on January 09, 2013
with hemoptysis and anemia. Vitals were
36.4 C (0), 65 bpm, 121/58mmHg
brachial, and Sa02 99% on room air on
admission. The pt has been coughing up
blood for several months and has severe
difficulty swallowing and consistent pain
in his throat. A bronchoscopy and CT
neck exam was performed Feb 11, 2013,
showing a 4 cm mass on the left side of
the patients larynx. Patient has multiple
lesions and masses, excessive mucous
secretions, and inflammation in the
throat. The patients increase in coughing
and laryngeal lesion is causing moderate
amount of hemoptysis. The pt was taking
Warfarin 6 mg PO daily, but because of
his high risk for bleeding the doctor held
this medication. The pt is now on 5000
units Fragmin s/c daily.

Client Goals

The nurse will manage and

minimize bleeding episodes

Client Outcomes

1.Client will remain free from

episodes of active bleeding by
18/1/13
- Skin for bruising
-Hemoptysis
- Blood in stool
- Nose bleeds
- Hematuria
2. Clients vital signs remain at
baseline by 18/1/13
3. Display laboratory results for
clotting times and factors within
normal range for individual by
18/1/13
4. Client will be educated about
action and effects of
anticoagulation therapy by
18/1/13 by showing an
understanding of the reason he is
on the medication (treatment)

modifications, blood replacement

therapy, or supportive interventions
(Lemone & Burke, 2000 p. 1280)

Interventions
Client

Literature-based Rationale for Interventions

Nursing

and possible bleeding

abnormalities (side effects) such
as bleeding from gums,
hemoptysis, blood in stool,
hematuria, nose bleeds

Evaluation

1.Client will report to

nurse and bleeding
episodes such as
-bleeding from gums
-hemoptysis
-blood in stool
-hematuria
-nose bleeds
2. Pt will avoid
activities that increase
the risk for bleeding
and ambulate carefully.
-shaving
-mobilizing
-using a soft bristled
tooth brush
- trimming
fingernail/toes
3.Client will express an
understanding of
treatments,
medications, and side
effects of
anticoagulation therapy

1.Nurse will monitor

vital signs for baseline
values
2.Nurse will monitor
for indications of
bleeding abnormalities
- Skin for bruising
-Hemoptysis
- Blood in stool
- Nose bleeds
- Hematuria
3.Monitor laboratory
values: INR, CBC
4.Teach the patient and
evaluate his
understanding of the
following: Treatments,
medications, and side
effects of
anticoagulation therapy.
5. Encourage the pt to
ambulate carefully and
refrain from high riskactivities.

N-1: Careful monitoring can detect early

changes in blood volume (Carpenito-Moyet
2010, p. 912).

Outcome 1: Partially MET

The pt did remain free from active bleeding
episodes. The patient still experiences frequent
episodes of hemoptysis, however. But this
bleeding was only a moderate amount throughout
the day.

N-2: Allows for early detection; these symptoms

indicate that the body is unable to clot effectively
and further examination and interventions may be Outcome 2: MET.
warranted to prevent hemorrhage (Rodgers, 2008 Clients vital signs remained stable q4 hrs.
p. 714).
T 36.4 C (O) P 65 bpm, weak BP 121/58 mmHg
brachial, supine, R 24/min labored, Sa02 98%
N-3: The therapeutic range for the INR is 2.0on room air.
3.0 (Carpenito-Moyet, 2010 p. 932).
N:4 Knowledge enhances anxiety reduction and
allows the patient to understand health status and
implement health-promoting behaviors
(Rodgers, 2008 p. 714).
N-5, C-2: The patient is at high risk for bleeding;
simply bumping into objects places the pt at risk
for bruising or frank bleeding from simple
injuries (Rodgers, 2008 p. 714).
C-1: The patient who has received thrombolytic
therapy or who is receiving anticoagulant therapy
is at risk for hemorrhage due to alteration of
normal clotting mechanisms. It is important for
the patient to remain alert for evidence of
bleeding. (Lemone & Burke, 2000).
C-3: The level of knowledge of the main side
effect of warfarin and the signs and symptoms of
bleeding by patients is poor, indicating the
majority of patients being discharged home
after being commenced on warfarin, lacked
awareness of key aspects of their warfarin
treatment. It is essential for patients to have
clear knowledge on the signs of

Outcome 3: NO DATA AVAILABLE

The last INR lab data was on 16/1/13 at 1.2,
which is within normal limits
18/1/13 RBC 4.47 (L), Hgb 113 (L), HcT .38 (L)
Outcome 4: MET
I had a discussion with the patient about his
anticoagulant medications. He said the doctor
spoke to him on 17/1/13 to explain why his
Warfarin was being held. We discussed the side
effects of anticoagulation therapy and he
understood that his medication was held because
he was at a high risk for bleeding. We also
discussed safety precautions to take to prevent
bleeding episodes, and things to watch for, such
as: bleeding from gums, bleeding in urine or stool,
nose bleeds, and coughing up blood that was more
than usual for the pt.
Overall Goal: No serious bleeding episodes
occurred while I was with my pt. He did have
hemoptysis but this is usual for the pt. The
hemoptysis was only a moderate amount and I

bleeding. . (Westaway, Cruickshank, Roberts, &

Esterman, 2010).

informed the pt to notify me if the amount of

bleeding increased during the day.