NURSING DIAGNOSIS: Injury, risk for [hemorrhage]
Risk factors may include
- Abnormal blood profile; altered clotting factors (decreased production of prothrombin, fibrinogen, and factors VIII, IX, and X; impaired vitamin Kabsorption; and release of thromboplastin)
- Portal hypertension, development of esophageal varices
- Maintain homestasis with absence of bleeding
- Demonstrate behaviors to reduce risk of bleeding.
Nursing Interventions & Rationale
|Assess for signs/symptoms of GI bleeding; e.g., check all secretions for frank or occult blood. Observe color and consistency of stools, NG drainage, or vomitus.||The GI tract (esopahgus and rectum) is the most usual source of bleeding because of its mucosal fragility and alterations in hemostasis associated with cirrhosis.|
|Observe for presence of petechiae, ecchymosis, bleeding from one or more sites.||Subacute disseminated intravascular coagulation (DIC) may develop secondary to altered clotting factors.|
|Monitor pulse, BP (and CVP if available).||An increased pulse with decreased BP and CVP can indicate loss of circulating blood volume, requiring further evaluation.|
|Note changes in mentation/level of consciousness.||Changes may indicate decreased cerebral perfusion secondary to hypovolemia, hypoxemia.|
|Avoid rectal temperature; be gentle with GI tube insertions.||Rectal and esophageal vessels are most vulnerable to rupture.|
|Encourage use of soft toothbrush, electric razor, avoiding straining for stool, forceful nose blowing, and so forth.||In the presence of clotting factor disturbances, minimal trauma can cause mucosal bleeding.|
|Use small needles for injections. Apply pressure to small bleeding/venipuncture sites for longer than usual.||Minimizes damage to tissues, reducing risk of bleeding/hematoma.|
|Recommend avoidance of aspirin-containing products.||Prolongs coagulation, potentiating risk of hemorrhage.|
|Monitor Hb/Hct and clotting factors.||Indicators of anemia, active bleeding, or impending complications (e.g., DIC).|
|Administer medications as indicated:
|Promotes prothrombin synthesis and coagulation if liver is functional. Vitamin C deficiencies increase susceptibility of GI system to irritation/bleeding.
Prevents straining for stool with resultant increase in intra-abdominal pressure and risk of vascular rupture/hemorrhage.
|Provide gastric lavage with room temperature/cool saline solution orwater as indicated.||In presence of acute bleeding, evacuation of blood from GI tract reduces ammonia production and risk of hepatic encephalopathy.|
|Assist with insertion/maintenance of GI/esophageal tube (e.g., Sengstaken-Blakemore tube).||Temporarily controls bleeding of esophageal varices when control by other means (e.g., lavage) and hemodynamic stability cannot be achieved.|
|Prepare for surgical procedures, e.g., direct ligation (banding) or varices, esophagogastric resection, splenorenal-portacaval anastomosis.||May be needed to control active hemorrhage or to decrease portal and collateral blood vessel pressure to minimize risk of recurrence of bleeding.