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Risk for Injury — Liver Cirrhosis

NURSING DIAGNOSIS: Injury, risk for [hemorrhage]

LC-Risk for Injury
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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
Desired Outcomes
  • Maintain homestasis with absence of bleeding
  • Demonstrate behaviors to reduce risk of bleeding.

Nursing Interventions & Rationale

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:

Supplemental vitamins (e.g.,vitamins K, D, and C);
Stool softeners.
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.

 

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