Medical Surgical Nursing

(razors) with safer items.

5. Observe each stool for color,

consistency, and amount.

6. Be alert for symptoms of

anxiety, epigastric fullness,

weakness, and restlessness.

7. Test each stool and emesis

for occult blood.

8. Observe for hemorrhagic

manifestations: ecchymosis,

epistaxis, petechiae, and

bleeding gums.

9. Record vital signs at frequent

intervals, depending on

patient acuity (every 1–4 h).

10. 
    

    Keep patient quiet and limit
    activity.

    
    


11. 
    

    Assist physician in passage

    
    

of tube for esophageal

balloon tamponade, if its

insertion is indicated.

12. Observe during blood

transfusions.

13. 
    

    Measure and record nature,
    time, and amount of vomitus.

    
    


14. 
    

    Maintain patient in fasting

    
    

state, if indicated.

15. Administer vitamin K as

prescribed.

16. Remain with patient during

episodes of bleeding.

17. 
    

    Offer cold liquids by mouth
    when bleeding stops (if
    prescribed).

    
    


18. 
    

    Institute measures to prevent

    
    

disturb patient further

4. Avoids cuts and bleeding

5. Permits detection of bleeding

in gastrointestinal tract

6. May indicate early signs of

bleeding and shock

7. Detects early evidence of

bleeding

8. Indicates altered clotting

mechanisms

9. Provides baseline and evidence

of hypovolemia, and

hemorrhagic shock

10. Minimizes risk of bleeding and

straining

11. Promotes nontraumatic

insertion of tube in anxious

and combative patient for

immediate treatment of

bleeding

12. Permits detection of

transfusion reactions (risk is

increased with multiple blood

transfusions needed for active

bleeding from esophageal

varices)

13. Assists in evaluating extent of

bleeding and blood loss

14. Reduces risk of aspiration of

gastric contents and minimizes

risk of further trauma to

esophagus and stomach by

preventing vomiting

15. Promotes clotting by providing

fat-soluble vitamin necessary

 Exhibits absence of frank

bleeding from

gastrointestinal tract

 Exhibits absence of

restlessness, epigastric

fullness, and other

indicators of hemorrhage

and shock

 Exhibits negative results

of test for occult

gastrointestinal bleeding

 Is free of ecchymotic areas

or hematoma formation

 Exhibits normal vital signs

 Maintains rest and

remains quiet if active

bleeding occurs

 Identifies rationale for

blood transfusions and

measures to treat bleeding

 Uses measures to prevent

trauma (eg, uses soft

toothbrush, blows nose

gently, avoids bumps and

falls, avoids straining

during defecation)

 Experiences no side

effects of medications

 Takes all medications as

prescribed

 Identifies rationale for

precautions with use of all

medications

 Cooperates with

treatment.