Bruise, Hematoma
Also Consider: Abrasion, Fractures/Dislocations, Dizziness, Head Injury, Laceration, Sprain/Strain, Unsteadiness, Weakness (general), Wound (surgical/traumatic)
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Tasks
Evaluate for and treat any other injury that may be present, regardless of how old the bruise or hematoma appears. Other injury may be in the same location as the bruise or elsewhere on the body.
Evaluate for and treat any acute illness that may have contributed to injury, bruise, or bleeding.
Review circumstances leading to the bruise/hematoma to prevent recurrence
1. Take Vital Signs
Temperature:
Blood Pressure lying:
Blood Pressure standing:
Heart Rate:
Respiratory Rate:
Oxygen Saturation:
2. Evaluate Symptoms and Signs
Measurements and appearance/color of bruise(s), hematoma. Avoid attempting to use color to determine age of bruise.
Tenderness or pain in bruised area
Injuries anywhere on the body (other bruising, laceration, fractures, deformity), head trauma
Assess all joints for change in normal range of motion, weight bearing, etc
Acute mental status change
Not eating or drinking as much as usual
Pain assessment: exact locations, persistent or intermittent, exacerbating factors
Fainting, dizziness or lightheadedness when standing up
Signs of dehydration
Diaphoresis: Cold, clammy, pale skin
Respiratory: New cough, abnormal lung sounds, Accessory muscle breathing, pursed lip breathing, Respiratory distress
Cardiovascular: Chest pain, new irregular pulse, cyanosis, mottling, edema
GI: Nausea, vomiting, diarrhea, constipation, abdominal distention or tenderness, rebound tenderness, bowel sounds, blood in stool
GU: pain with urination, blood in urine
Neurologic changes: consciousness/alertness, orientation, weakness, gait changes (unsteadiness, loss of coordination or balance)
3. Take Action using SBAR Report:
Presence of other, significant symptoms or signs of illness
Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.
Immediately notify the medical staff & resident representative
With any suspected serious injury (e.g., fracture, laceration requiring sutures), new orthostatic changes, or rapidly enlarging hematoma
Notify medical staff & resident representative within the next 16 hours.
Persistent pain without suspicion of serious injury, or
Minor injury potentially requiring medical intervention, slowly enlarging hematoma, or new bruising in a patient on anticoagulant medication.
Notify medical staff on the next business day
Bruise with no significant injury
Notify medical staff at the next regular rounds
Bruise with no injury or symptoms, bruising easily
SBAR Report
Situation: "(Bruise) (Hematoma) associated with:" (suspected serious injury) (persistent pain) (injury potentially requiring medical intervention)
Background:
Reason the patient is in the nursing home (rehab for___, long term care for __).
History of easy bruising or bleeding
Recent falls or other sources of injury
Nature of any injury
Patient on anticoagulant therapy, aspirin, etc.
Circumstances leading to bruise/hematoma.
Other recent bruising or bleeding.
Abnormal Vital Signs or orthostatic changes
MOLST / Advance Directives
Unrelieved pain
Recent illness, antibiotics, medication changes, surgery
General observation of patient condition
Abnormal findings on lung, cardiovascular, abdomen, neurologic or skin observations.
Signs or symptoms of pain, infection, dehydration, head trauma
Medications increasing injury risk: Antipsychotics, antidepressants, anticonvulsants, sedatives/antianxiety, dementia meds, narcotics, diuretics, antihypertensives
Assessment: I am concerned about: __________
Recommendations/Requests:
Labs: CBC with diff, CMP/Chem14, Drug levels
INR if patient is on warfarin
X-ray of injured areas
Stop anticoagulant, aspirin
Vitamin K if on warfarin
“Hold” parameters for medicines that lower blood pressure
Cold therapy to bruise/hematoma site
Pain Medication
IV or SC (clysis) fluids
Other:
Clarify expectations for care, interventions, and illness course/prognosis. Repeat any telephone orders back to the provider to ensure that they are correct and complete
4. Implement Management Plan
Complete injury report per facility policy/procedure
Neuro checks per facility policy/procedure
Monitor vital signs every 4-8 hrs for 2-3 days
Place on Intake & Output monitoring if blood loss suspected
Repeat observations of bruise/hematoma at least daily and more frequently if changes are noted.
Place on 24-hour report for 2-3 days
Obtain lab results (if ordered), and notify medical as needed of significantly abnormal values in lab tests (refer to appropriate Situation)
Update care plan regarding injury risk, anticoagulation treatment, assistance needed with ADLs, supervision for safety, restorative needs
Review status and plan of care with designated representative
2025-04-26
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