Risk factors may include
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Maintain and improve tissue perfusion as evidenced by stabilized vital signs, warm skin, palpable peripheral pulses, ABGs within client norms, and adequate urine output.
Nursing intervention with rationale:
1. Investigate changes in level of consciousness and reports of dizziness or headache.
Rationale: Changes may reflect inadequate cerebral perfusion as a result of reduced arterial blood pressure. Note: Changes in sensorium may also reflect elevated ammonia levels or hepatic
encephalopathy in client with liver disease.
2. Investigate reports of chest pain. Note location, quality, duration, and what relieves pain.
Rationale: May reflect cardiac ischemia related to decreased perfusion. Note: Impaired oxygenation status resulting from blood loss can bring on myocardial infarction (MI) in client with cardiac disease.
3. Auscultate apical pulse. Monitor cardiac rate and rhythm, if continuous electrocardiogram (ECG) available and indicated.
Rationale: Dysrhythmias and ischemic changes can occur as a result of hypotension, hypoxia, acidosis, electrolyte imbalance, or cooling near the heart if cold saline lavage is used to control bleeding.
4. Assess skin for coolness; pallor; diaphoresis; delayed capillary refill; and weak, thready peripheral pulses.
Rationale: Vasoconstriction is a sympathetic response to lowered circulating volume and may occur as a side effect of vasopressin administration.
5. Note urinary output and specific gravity. Insert Foley catheter to accurately measure urine, as indicated.
Rationale: Decreased systemic perfusion may cause kidney ischemia and failure, manifested by decreased urine output. Acute tubular necrosis (ATN) may develop if hypovolemic state is
6. Note reports of abdominal pain, especially sudden, severe pain or pain radiating to shoulder.
Rationale: Pain caused by gastric ulcer is often relieved after acute bleeding because of buffering effects of blood. Continued severe or sudden pain may reflect ischemia due to vasoconstrictive
therapy, bleeding into biliary tract (hematobilia), or perforation with onset of peritonitis.
7. Observe skin for pallor and redness. Massage gently with lotion. Change position frequently.
Rationale: Compromised peripheral circulation increases risk of skin breakdown as demonstrated by redness over bony prominence that does not blanch when digital pressure applied.
8. Monitor ABGs and pulse oximetry.
Rationale: Identifies hypoxemia and effectiveness of and need for therapy.
9. Provide supplemental oxygen, if indicated.
Rationale: Treats hypoxemia and lactic acidosis during acute bleed.
10. Administer IV fluids, as indicated.
Rationale: Maintains circulating volume and perfusion. A guideline for fluid replacement is 3 mL of fluid for each 1 mL of blood lost.