Medical-surgical Nursing Demystified

CHAPTER 4 Hematologic System^201

NURSING DIAGNOSIS

• Impaired physical mobility


• Risk for acute pain

NURSING INTERVENTIONS

• Monitor vital signs for changes.


• Monitor for signs of pulmonary embolism, shortness of breath, chest pain,
  tachycardia (rapid heart rate), tachypnea (rapid respirations), and diaphoresis
  (sweating).


• Avoid massaging the area to lessen the possibility of dislodging the clot.


• Intermittent warm, moist soaks. Assess skin between changes.


• Follow weight-dosed heparin protocol.


• Monitor lab results: PT, PTT, INR, and CBC with platelets.


• Low molecular weight heparin (enoxaparin, dalteparin).


• Warfarin orally.


• Monitor for signs of bleeding or bruising.


• Instruct patient to:
  
  
  • Report signs of bleeding or bruising to physician, nurse practitioner, or
    physician assistant.
  
  
  • Avoid injury.
  
  
  • Use of electric razor and soft toothbrush; avoid flossing between teeth.
  
  
  • Diet restrictions, and to check with health care provider or pharmacist
    about interactions of any medications, if on warfarin as outpatient.
  
  
  
  

Idiopathic Thrombocytopenic Purpura (ITP)

WHAT WENT WRONG?

An autoimmune disorder in which antibodies are developed to the patient’s own
platelets. Antibodies attach to the platelets and macrophages within the spleen. The

12