Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Blood Loss Severity
Be free of signs of bleeding in GI aspirate or stools, with stabilization of Hgb and Hct.
Demonstrate improved fluid balance as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor, and prompt capillary refill.
Nursing intervention with rationale:
1. Note color and characteristics of vomitus, nasogastric (NG) tube drainage, and stools.
Rationale: The first step in managing bleeding is to determine its location. Bright red blood that does not clear signals recent or acute arterial bleeding, perhaps caused by gastric ulceration; dark red blood may be old blood that has been retained in intestine or venous bleeding from varices. Coffee-ground appearance is suggestive of partially digested blood from slowly oozing area. Undigested food indicates obstruction or gastric tumor. In a rapid upper GI bleed, stool color may be red or maroon because of rapid transit time through the GI tract.
2. Monitor vital signs; compare with client’s normal and previous readings. Take blood pressure (BP) in lying, sitting, and standing positions when possible.
Rationale: Changes in BP and pulse may be used for rough estimate of blood loss; BP less than 90 mm Hg and pulse greater than 110 suggest a 25% decrease in volume, or approximately 1,000 mL. Postural hypotension reflects a decrease in circulating volume. Note: Heart rate may not rise above normal until up to 30% of total blood volume is lost.
3. Note client’s individual physiological response to bleeding, such as changes in mentation, weakness, restlessness, anxiety, pallor, diaphoresis, tachypnea, and temperature elevation.
Rationale: Symptomatology is useful in gauging severity and length of bleeding episode. Worsening of symptoms may reflect continued bleeding, inadequate fluid replacement, and shock.
4. Measure central venous pressure (CVP) if available.
Rationale: Reflects circulating volume and cardiac response to bleeding and fluid replacement. CVP values between 5 and 20 cm H2O usually reflect adequate volume.
5. Monitor intake and output (I&O) and correlate with weight changes. Measure blood and fluid losses via emesis, gastric suction or lavage, and stools.
Rationale: Provides guidelines for fluid replacement.
6. Keep accurate record of subtotals of solutions and blood products during replacement therapy.
Rationale: Potential exists for overtransfusion of fluids, especially when volume expanders are given before blood transfusions.
7. Maintain bedrest; prevent vomiting and straining at stool. Schedule activities to provide undisturbed rest periods. Eliminate noxious stimuli.
Rationale: Activity and vomiting increases intra-abdominal pressure and can predispose to further bleeding.
8. Elevate head of bed during antacid gavage.
Rationale: Prevents gastric reflux and aspiration of antacids, which can cause serious pulmonary complications.
9. Note signs of renewed bleeding after cessation of initial bleed.
Rationale: Increased abdominal fullness and distention, nausea or renewed vomiting, and bloody diarrhea may indicate return of bleeding.
10. Observe for secondary bleeding from nose or gums, oozing from puncture sites, or appearance of ecchymotic areas following minimal trauma.
Rationale: Loss of or inadequate replacement of clotting factors may precipitate development of DIC.