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Nursing Diagnosis and Nursing Interventions for Hematemesis Melena

Nursing Diagnosis for Hematemesis Melena

  1. Deficient Fluid Volume related to bleeding (loss of active)
  2. Ineffective tissue perfusion related to hypovolemia


Nursing Interventions for Hematemesis Melena

Nursing Diagnosis I
Deficient Fluid Volume related to bleeding (loss of active)

Goal :
  • Fluid requirements are met.
  • Vital signs within normal limits, good skin turgor, moist mucous membranes, the production of urine output is balanced, not vomiting blood and stools are not black.

Nursing Interventions:
  1. Record the characteristics of vomiting and / or drainage.
    Rational:
    Assist in distinguishing gastric distress. Bright red blood indicates the presence or acute arterial bleeding, probably due to gastric ulcer; dark red blood probably old blood (stuck in the intestines) or bleeding from varicose veins.
  2. Monitor vital signs; compared with normal results of client / previous. Measure blood pressure with sitting, sleeping, standing if possible.
    Rational:
    Postural hypotension showed decreased circulating volume.
  3. Record the individual patient's physiological response to bleeding, such as mental changes, weakness, restlessness, anxiety, pale, sweaty, tachypnoea, the increase in temperature.
    Rational:
    Worsening of symptoms may indicate the continued bleeding or inadequate fluid replacement.
  4. Monitor input and output and connect them with changes in body weight. Measure blood loss / fluid through vomiting and defecation.
    Rational:
    Provide guidelines for fluid replacement.
  5. Maintain bed rest; prevent vomiting and stress at the time of defecation. Schedule of activities to provide a rest period without interruption.
    Rational:
    Activities / vomiting increased intra-abdominal pressure and can trigger further bleeding.
  6. Elevate head of bed for antacid drug administration.
    Rational:
    Prevent gastric reflux and aspiration of antacids which can cause serious lung complications.
  7. Collaboration:
    • Give fluid / blood as indicated.
      Rational:
      Replacement fluid hypovolaemia depends on the degree and duration of bleeding (acute / chronic).
    • Give antibiotics as indicated.
      Rational:
      It may be used when the infection causes chronic gastritis.
    • Supervise laboratory examination; eg Hb / Ht
      Rational: A tool to determine the need for blood replacement and oversee the effectiveness of therapy.

Nursing Diagnosis II
Ineffective tissue perfusion related to hypovolemia

Goal :
Effective tissue perfusion

Expected results :
Maintain / improve tissue perfusion with evidence: stable vital signs, skin warm, palpable peripheral pulse, urine output adequate.

Nursing Intervention :
  1. Monitor changes in level of consciousness, dizziness complaints / headaches.
    Rational:
    The change may indicate inadequate cerebral perfusion due to arterial blood pressure.
  2. Auscultation apical pulse. Guard heart rate / rhythm when there is a continuous ECG.
    Rational:
    Change dysrhythmias and ischemia can occur as a result of hypotension, hypoxia, acidosis, electrolyte imbalance, or cooling near the heart area.
  3. Assess the skin to cold, pale, sweating, slow capillary filling, and peripheral pulse is weak.
    Rational:
    Vasoconstriction is a sympathetic response to the decline in circulation volume and / or may occur as a side effect of vasopressin.
  4. Note the report abdominal pain, especially sudden severe pain or pain spreading to shoulders.
    Rational:
    Pain caused by gastric ulcer, often disappear after acute hemorrhage due to buffer the effects of blood.
  5. Observations for pale skin, reddish. Massage with oil. Change positions frequently.
    Rational:
    Disturbances in peripheral circulation increases the risk of skin damage.
  6. Collaboration :
    • Provide supplemental oxygen as indicated.
      Rational:
      Treat hypoxemia and lactic acidosis during acute hemorrhage.
    • Give IV fluids as indicated.
      Rational:
      Maintain circulating volume and perfusion.

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