Nursing diagnosis: risk for Bleeding
Risk factors may include
Abnormal blood profile; altered clotting factors—decreased production of prothrombin, fibrinogen, and factors VIII, IX, and X; impaired vitamin K absorption; and release of thromboplastin
Portal hypertension, development of esophageal varices
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Maintain homeostasis with absence of bleeding.
Demonstrate behaviors to reduce risk of bleeding.
Nursing intervention with rationale:
1. Assess for signs and symptoms of GI bleeding; for instance, check all secretions for frank or occult blood. Observe color and consistency of stools, nasogastric (NG) drainage, or vomitus.
Rationale: The GI tract—esophagus and rectum—is the most usual source of bleeding because of its mucosal fragility and alterations in homeostasis associated with cirrhosis.
2. Observe for presence of petechiae, ecchymosis, and bleeding from one or more sites.
Rationale: Subacute disseminated intravascular coagulation (DIC) may develop secondary to altered clotting factors.
3. Monitor pulse, BP, and CVP, if available.
Rationale: An increased pulse with decreased BP and CVP may indicate loss of circulating blood volume, requiring further evaluation.
4. Note changes in mentation and LOC.
Rationale: Changes may indicate decreased cerebral perfusion secondary to hypovolemia or hypoxemia.
5. Avoid rectal temperature; be gentle with GI tube insertions.
Rationale: Rectal and esophageal vessels are most vulnerable to rupture.
6. Encourage use of soft toothbrush and electric razor, avoiding straining for stool, forceful nose blowing, and so forth.
Rationale: In the presence of clotting factor disturbances, minimal trauma can cause mucosal bleeding.
7. Use small needles for injections. Apply pressure to small bleeding or venipuncture sites for longer than usual.
Rationale: Minimizes damage to tissues, reducing risk of bleeding and hematoma.
8. Recommend avoidance of aspirin-containing products.
Rationale: Prolongs coagulation, potentiating risk of hemorrhage.
9. Monitor Hgb and Hct, platelets, and clotting factors.
Rationale: Indicators of anemia, active bleeding, or impending complications, such as DIC.
10. Administer medications, as indicated, for example: Supplemental vitamins, such as vitamins K, D, and C
Rationale: Promotes prothrombin synthesis and coagulation, if liver is functional. Vitamin C deficiencies increase susceptibility of GI system to irritation and bleeding.