The nurse determines that a patient with heparin-induced thrombocytopenia is at risk for bleeding. Which intervention should the nurse include in this patient's plan of care?
1. Avoid invasive procedures, such as rectal temperatures, urinary catheterizations, and parenteral injections.
2. Apply pressure to puncture sites for 3–5 minutes for arterial blood gases aspiration.
3. Give enemas to help the patient avoid straining during bowel movements.
4. Encourage the patient to brush the teeth thoroughly and rinse with alcohol-based mouthwash after each meal.
Correct Answer: 1
With bleeding disorders, any trauma carries the risk of extensive bleeding from platelet agglutination, due to removal of platelets by phagocytosis. Arterial puncture sites require holding 15–20 minutes, and venous punctures require 3–5 minutes to make sure a clot has formed in the patient with a prolonged clotting time. An enema is an invasive procedure, and the risk of bleeding from trauma is increased. The patient should be provided with stool softeners to avoid straining during a bowel movement. Brisk tooth-brushing and alcohol-based mouthwash are too strong for this patient, can lead to bleeding of the gums, and are not recommended.
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ANS:
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