Nursing Diagnosis for Hematemesis Melena
Nursing Interventions for Hematemesis Melena
Nursing Diagnosis I
Deficient Fluid Volume related to bleeding (loss of active)
Goal :
Nursing Interventions:
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 :
Related Articles :
- Deficient Fluid Volume related to bleeding (loss of active)
- 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:
- 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. - 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. - 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. - 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. - 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. - Elevate head of bed for antacid drug administration.
Rational:
Prevent gastric reflux and aspiration of antacids which can cause serious lung complications. - 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.
- Give fluid / blood as indicated.
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 :
- Monitor changes in level of consciousness, dizziness complaints / headaches.
Rational:
The change may indicate inadequate cerebral perfusion due to arterial blood pressure. - 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. - 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. - 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. - Observations for pale skin, reddish. Massage with oil. Change positions frequently.
Rational:
Disturbances in peripheral circulation increases the risk of skin damage.
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.
Related Articles :
- Nursing Assessment for Hematemesis Melena
- Haematemesis Melena
- Nursing Care Plan for Hematemesis Melena