Risk for Deficient Fluid Volume/Bleeding | Nursing Care Plan for Pancreatitis

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
Hydration
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.

Risk for Bleeding | Nursing Care Plan for Liver Cirrhosis

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
Coagulation Status
Maintain homeostasis with absence of bleeding.
Risk Control
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.

Risk for Bleeding | Nursing Care Plan for Upper Gastrointestinal (GI) Bleeding

Nursing diagnosis: risk for Bleeding related to Active fluid volume loss—hemorrhage

Possibly evidenced by

(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Blood Loss Severity

Be free of signs of bleeding in GI aspirate or stools, with stabilization of Hgb and Hct.

Hydration

Demonstrate improved fluid balance as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor, and prompt capillary refill.

Nursing intervention with rationale:

1. Note color and characteristics of vomitus, nasogastric (NG) tube drainage, and stools.

Rationale: The first step in managing bleeding is to determine its location. Bright red blood that does not clear signals recent or acute arterial bleeding, perhaps caused by gastric ulceration; dark red blood may be old blood that has been retained in intestine or venous bleeding from varices. Coffee-ground appearance is suggestive of partially digested blood from slowly oozing area. Undigested food indicates obstruction or gastric tumor. In a rapid upper GI bleed, stool color may be red or maroon because of rapid transit time through the GI tract.

2. Monitor vital signs; compare with client’s normal and previous readings. Take blood pressure (BP) in lying, sitting, and standing positions when possible.

Rationale: Changes in BP and pulse may be used for rough estimate of blood loss; BP less than 90 mm Hg and pulse greater than 110 suggest a 25% decrease in volume, or approximately 1,000 mL. Postural hypotension reflects a decrease in circulating volume. Note: Heart rate may not rise above normal until up to 30% of total blood volume is lost.

3. Note client’s individual physiological response to bleeding, such as changes in mentation, weakness, restlessness, anxiety, pallor, diaphoresis, tachypnea, and temperature elevation.

Rationale: Symptomatology is useful in gauging severity and length of bleeding episode. Worsening of symptoms may reflect continued bleeding, inadequate fluid replacement, and shock.

4. Measure central venous pressure (CVP) if available.

Rationale: Reflects circulating volume and cardiac response to bleeding and fluid replacement. CVP values between 5 and 20 cm H2O usually reflect adequate volume.

5. Monitor intake and output (I&O) and correlate with weight changes. Measure blood and fluid losses via emesis, gastric suction or lavage, and stools.

Rationale: Provides guidelines for fluid replacement.

6. Keep accurate record of subtotals of solutions and blood products during replacement therapy.

Rationale: Potential exists for overtransfusion of fluids, especially when volume expanders are given before blood transfusions.

7. Maintain bedrest; prevent vomiting and straining at stool. Schedule activities to provide undisturbed rest periods. Eliminate noxious stimuli.

Rationale: Activity and vomiting increases intra-abdominal pressure and can predispose to further bleeding.

8. Elevate head of bed during antacid gavage.

Rationale: Prevents gastric reflux and aspiration of antacids, which can cause serious pulmonary complications.

9. Note signs of renewed bleeding after cessation of initial bleed.

Rationale: Increased abdominal fullness and distention, nausea or renewed vomiting, and bloody diarrhea may indicate return of bleeding.

10. Observe for secondary bleeding from nose or gums, oozing from puncture sites, or appearance of ecchymotic areas following minimal trauma.

Rationale: Loss of or inadequate replacement of clotting factors may precipitate development of DIC.