NURSING CARE PLAN 31-1
Patient With Thrombocytopenia
NURSING DIAGNOSIS*: Impaired oral mucous membrane related to low platelet counts and/or effects of
pathologic conditions and treatment as evidenced by oral bleeding and blood-filled bullae
PATIENT GOAL: Experiences lesion-free oral mucosa without bleeding
Outcomes (NOC)
Interventions (NIC) and Rationales
Oral Hygiene
• Bleeding _____
• Oral mucosa lesions _____
Oral Health Restoration
• Monitor lips, tongue, mucous
membranes, tonsillar fossae, and gums
for moisture, color, texture, presence of
debris, and infection using good
lighting and a tongue blade to provide
information for planning interventions.
• Assist the patient to select soft, bland,
and nonacidic foods to decrease
irritation of oral mucosa.
• Use a soft toothbrush for removal of
dental debris.
• Use toothettes or disposable foam
swabs to stimulate and clean cavity
with minimal trauma to gingiva.
• Instruct and assist patient to perform
oral hygiene after eating and as often as
needed to avoid breakdown of oral
mucosa.
• Avoid use of lemon-glycerin swabs and
commercial mouthwashes to prevent
excessive drying of the mucosa.
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None
NURSING DIAGNOSIS: Risk for bleeding related to decreased platelets, treatment-related side effects,
and/or inherent coagulopathies
PATIENT GOALS:
1. Maintains tissue integrity
2. Has no evidence of bleeding or bruising
Outcomes (NOC)
Interventions (NIC) and Rationales
Blood Coagulation
• Bleeding _____
• Bruising _____
• Petechiae _____
• Ecchymosis _____
• Purpura _____
• Hematuria _____
• Hemoptysis _____
Bleeding Precautions
• Monitor for signs and symptoms of
persistent bleeding (e.g., check all
secretions for frank or occult blood) to
detect internal bleeding.
• Monitor coagulation studies, including
prothrombin time (PT), partial
thromboplastin time (PTT), fibrinogen,
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None
•
•
•
•
•
•
fibrin degradation/split products, and
platelet counts to determine bleeding
risk.
Avoid injections (IV, IM,
subcutaneous) to prevent bleeding into
tissue surrounding puncture site.
Use electric razor instead of straightedge razor 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.
Instruct the patient/caregiver to avoid
aspirin or other anticoagulants to
prevent additional bleeding risk.
NURSING DIAGNOSIS: Deficient knowledge related to lack of information regarding the disease process,
activity, and medication as evidenced by frequent questioning about disease management, anxiety, restlessness
PATIENT GOAL: Verbalizes required knowledge and skills to manage disease process at home
Outcomes (NOC)
Interventions (NIC) and Rationales
Knowledge: Disease Process
 Specific disease process ____
 Cause and contributing factors _____
 Signs and symptoms of disease ____
 Usual course of disease process ____
 Signs and symptoms of disease
complications ____
 Precautions to prevent complications of
disease _____
Teaching: Disease Process
 Appraise 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
knowledgeable and able to manage
own care or direct others in care.
 Refer patient to local community
agencies/support groups for continued
education and support.
Measurement Scale
1 = No knowledge
2 = Limited knowledge
3 = Moderate knowledge
4 = Substantial knowledge
5 = Extensive knowledge
 Provide the phone numbers to call if
complications occur to enable control
of complications.
*Nursing diagnoses listed in order of priority.