Risk for Bleeding

related to portal hypertension and altered clotting factors

Desired Outcomes: The patient is free of bleeding/hemorrhage as evidenced by blood

pressure (BP) at least 90/60 mm Hg; heart rate (HR) 100 bpm or less; warm extremities;
distal pulses greater than 2 on a 0-4 scale; brisk capillary refill (less than 2 sec); and
orientation to person, place, and time. Bruising, melena, and hematemesis are absent.

 Assess vital signs (VS) q4h (or more frequently if VS are outside of the
patient’s baseline values).
Upper GI hemorrhage is common in patients with chronic liver
disease and can result from esophageal varices, portal
hypertensive gastropathy, duodenal or gastric ulcers, or Mallory-
Weiss tear (mucosal laceration at the juncture of the distal
esophagus and proximal stomach). Early diagnosis is essential to
enable appropriate intervention. Hypotension and increased HR, as
well as cool extremities, delayed capillary refill, decreased
amplitude of distal pulses, mental status changes, and decreasing
level of consciousness (LOC), are indicators of hypovolemia and
hemorrhage.

 Assess for signs of bleeding and notify the health care provider of
significant findings.
Bruising, melena, and hematemesis are signs of bleeding. Altered VS,
irritability, air hunger, pallor, and weakness are signs of
significant bleeding and necessitate prompt intervention.

 Inspect stools for the presence of blood; perform stool occult blood test as
indicated.
This is an assessment for bleeding within the GI tract.

 Monitor PT and INR for abnormality. INR: Normal range is less than 2.0 sec for
patients not receiving anticoagulant therapy.
PT: Normal range is 10.5-13.5 sec. A PT that is prolonged signals the
patient is at risk for bleeding.

 Teach the patient to avoid swallowing foods that are chemically or

mechanically irritating.
Rough or spicy foods, hot foods, hot liquids, and alcohol may be
injurious to the esophagus and result in bleeding.

 Teach the importance of avoiding actions such as sneezing, lifting, or

vomiting.
These actions increase intraabdominothoracic pressure, which can
result in bleeding.
  Administer stool softeners as prescribed.
Stool softeners help prevent straining with defecation, which puts
patients at risk for bleeding.

 As appropriate, encourage intake of foods rich in vitamin K (e.g., spinach,

cabbage, cauliflower, liver).
These foods may help decrease PT.

 As often as possible, avoid invasive procedures such as giving injections

and taking rectal temperatures.
If clotting is altered, invasive procedures could result in prolonged
bleeding.

 Monitor the patient undergoing band ligation or injection sclerotherapy of

varices for increased HR, decreased BP, pallor, weakness, and air
hunger.
These are signs of esophageal perforation caused by the treatment of
varices, whether by injection, cautery, or the scope itself.

 If signs of perforation occur, notify the health care provider immediately,

keep the patient nothing by mouth (NPO), and prepare for gastric
suction. Administer antibiotics as prescribed to prevent infection.

NPO status and gastric suction prevent leakage of fluid, secretions, or

food through the perforation into the mediastinum. This
emergency situation necessities immediate intervention.