Nursing diagnosis: risk for deficient Fluid Volume/Bleeding
Risk factors may include
Excessive losses—vomiting, gastric suctioning
Increase in size of vascular bed (vasodilation effects of kinins)
Third-space fluid transudation, ascites formation
Alteration of clotting process, hemorrhage
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Maintain adequate hydration as evidenced by stable vital signs, good skin turgor, prompt capillary refill, strong peripheral pulses, and individually appropriate urinary output.
Nursing intervention with rationale:
1. Auscultate heart sounds; note rate and rhythm. Monitor and document rhythm and changes.
Rationale: Cardiac changes and dysrhythmias may reflect hypovolemia or electrolyte imbalance, commonly hypokalemia and hypocalcemia. Hyperkalemia may occur related to tissue necrosis, acidosis, and renal insufficiency and may precipitate lethal dysrhythmias if uncorrected. Note: Cardiovascular complications are common in severe pancreatitis and include myocardial infarction (MI), pericarditis, and pericardial effusion with or without tamponade.
2. Monitor blood pressure (BP), noting trends. Measure central venous pressure (CVP), if available.
Rationale: Fluid sequestration with shifts into third space, bleeding, and release of vasodilators (kinins) and cardiac depressant factor triggered by pancreatic ischemia may result in profound hypotension. Reduced cardiac output and poor organ perfusion can precipitate widespread systemic complications. Systemic infection (septic shock) is also possible, exacerbating hypovolemic status.
3. Investigate changes in sensorium: confusion and slowed responses.
Rationale: Changes may be related to hypovolemia, hypoxia, electrolyte imbalance, or impending delirium tremens (in client with acute pancreatitis secondary to excessive alcohol intake). Severe pancreatic disease may cause toxic psychosis.
4. Measure intake and output (I&O), including vomiting or gastric aspirate, and diarrhea. Calculate 24-hour fluid balance.
Rationale: Indicators of replacement needs and effectiveness of therapy.
5. Note decrease in urine output (less than 400 mL/24 hours).
Rationale: Oliguria may occur, signaling renal impairment or acute tubular necrosis (ATN), related to increase in renal vascular resistance or altered renal blood flow.
6. Record color and character of gastric drainage, measure pH, and note presence of occult blood.
Rationale: Risk of gastric hemorrhage is high.
7. Weigh, as indicated; correlate with calculated fluid balance.
Rationale: Weight loss may suggest hypovolemia; however, edema, fluid retention, and ascites may be reflected by increased or stable weight, even in the presence of muscle wasting.
8. Note poor skin turgor, dry skin and mucous membranes, or reports of thirst.
Rationale: Further physiological indicators of dehydration.
9. Observe and record peripheral and dependent edema. Measure abdominal girth if ascites present.
Rationale: Edema and fluid shifts occur as a result of increased vascular permeability, sodium retention, and decreased colloid osmotic pressure in the intravascular compartment.
10. Inspect skin for petechiae, hematomas, and unusual wound or venipuncture bleeding. Note hematuria, mucous membrane bleeding, and bloody gastric contents.
Rationale: Disseminated intravascular coagulation (DIC) may be initiated by release of active pancreatic proteases into the circulation. The most frequently affected organs are the kidneys, skin, and lungs.