About
Acute bleeding r/t gastrointestinal disorders including ulcers, colitis, perforation, trauma, cancer.
Assess
May have presence of hypotension, tachycardia, diaphoresis, flushing, decreased urine output.
Complications
Cardiac Arrest- fluid resuscitation, CPR, electrolyte replacement, administer blood
Hypovolemic Shock- same as above, trendelenburg position for low blood pressure
Diagnosis
Fluid volume deficit r/t hemorrhage
Goals
Client will have stable blood pressure and hemoglobin/ hematocrit.
Interventions
- Assess for occult blood or coffee ground emesis.
- Monitor vital signs, notify physician if sudden hypotension and tachycardia.
- Monitor for abdominal discomfort.
- Monitor CBC, notify if significant drop in hemoglobin or hematocrit.
- Monitor for arrhythmias r/t fluid volume deficit.
- Maintain NPO, may need surgery to stop internal bleeding.
- Insert NG Tube as ordered.
- Administer analgesics, as ordered, as long as respiratory status not compromised.
- Type and cross and transfuse, maintain patent IV line, administer fluid boluses per IV as ordered.
- Monitor for signs/ symptoms of complications.
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