Which nursing intervention is appropriate for the patient diagnosed with heparin-induced thrombocytopenia who has the nursing diagnosis of Risk for Bleeding?

Question

1. Avoid invasive procedures, such as rectal temperatures, urinary catheterizations, and parenteral injections.
2. Hold pressure on laboratory testing venipuncture sites for at least 15 mintues.
3. Give enemas to avoid straining during bowel movements.
4. Encourage frequent independent ambulation.

Answer 1

1
Rationale 1: With bleeding disorders, any trauma carries the risk of extensive bleeding from platelet agglutination, which results in prolonged bleeding due to removal of platelets by phagocytosis.
Rationale 2: Venous punctures require 5 minutes to make sure a clot has formed in the patient who has a prolonged clotting time.
Rationale 3: An enema is an invasive procedure, and the patient's risk of bleeding from trauma is increased. The patient should be provided with stool softeners to avoid straining during a bowel movement, but enemas should not be given.
Rationale 4: The patient who has a risk for bleeding should be assisted as necessary with activities of daily living and ambulation to avoid injury.