About
Potentially life-threatening disruption in homeostasis of clotting factors resulting from an underlying condition such as sepsis, trauma, shock, tumors, allergic reactions, etc.
Assess
Bleeding, clotting, decreased platelets, increased PT, PTT, INR, underlying conditions ( sepsis, cancer, etc).
Complications
Hemorrhage, Pulmonary embolism, MI, CVA, DVT, multi-system organ failure, death
Diagnosis
- Fluid volume deficit related to blood loss.
- Impaired tissue perfusion related to clots and blockages in circulation.
- Anxiety related to fear of death and sense of impending doom.
Goals
- The client will maintain adequate fluid balance with greater than 30 cc/ hour of urine output.
- The client will have positive sensation, peripheral pulses, movement to extremities.
- The client will verbalize concerns and fears related to diagnosis and treatment options.
Interventions
- Assess PT, PTT, INR, Platelets, CBC frequently.
- Assess respiratory status, skin integrity, intake and output, peripheral pulses, sensation, neuro checks, vitals frequently.
- Monitor for bleeding and hemorrhage.
- Administer fluids, oxygen, electrolytes, vasopressors, transfusion, heparin as indicated by physician.
- Maintain bed rest to prevent injury.
- Reposition patient every two hours.
- Explain all procedures and treatments to patients.
- Encourage opportunities for client to express feelings and concerns regarding diagnosis and treatment.
- Avoid injections, invasive procedures, NSAIDS, ASA, OTC medications.
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