(blood pressure,
pulse, respiratory
rate) every 4 h or
more frequently,
depending on acuity.
b. Assess skin
temperature, level of
consciousness every
4 hours or more
frequently, depending
on acuity.
c. Monitor
gastrointestinal
secretions and output
(emesis, stool for
occult or obvious
bleeding). Test
emesis for blood
once per shift and
with any color
change. Hematest
each stool.
d. Monitor hematocrit
and hemoglobin for
trends and changes.
- Avoid activities that increase
intra-abdominal pressure
(straining, turning).
a. Avoid
coughing/sneezing.
b. Assist patient to turn.
c. Keep all needed
items within easy
reach.
d. Use measures to
prevent constipation
such as adequate
fluid intake; stool
could lead to rupture and
bleeding of esophageal or
gastric varices
3. Equipment, medications, and
supplies will be readily
available if patient
experiences bleeding from
ruptured esophageal or
gastric varices.
4. Gastrointestinal bleeding and
hemorrhage require
emergency measures (eg,
insertion of Blakemore tube,
administration of fluids and
medications).
5. The patient is at high risk for
respiratory complications,
including asphyxiation if
gastric balloon of tamponade
tube ruptures or migrates
upward.
6. The patient who experiences
hemorrhage is very anxious
and fearful; minimizing
anxiety assists in control of
hemorrhage.
7. Risk of rebleeding is high
with all treatment modalities
used to halt gastrointestinal
bleeding.
8. Family members are likely to
be anxious about the
patient's status; providing
information will reduce their
anxiety level and promote
more effective coping.
9. Risk of rebleeding is high.
Subtle signs may be more
a. Monitor vital signs
(blood pressure,
pulse, respiratory
rate) every 4 h or
more frequently,
depending on
acuity.
b. Assess skin
temperature, level
of consciousness
every 4 hours or
more frequently,
depending on
acuity.
c. Monitor
gastrointestinal
secretions and
output (emesis,
stool for occult or
obvious bleeding).
Test emesis for
blood once per
shift and with any
color change.
Hematest each
stool.
d. Monitor
hematocrit and
hemoglobin for
trends and
changes.
11. Avoid activities that
increase intra-abdominal
pressure (straining,
turning).
a. Avoid
coughing/sneezing.
b. Assist patient to
turn.
