Assessment - Nursing Care Plan for Hematemesis and Melena
Nursing Care Plan for Hematemesis and Melena
Physiological Assessments
1. Oxygen
Assess:
2. Fluids
Circumstances which need to be assessed on the client with hematemesis and melena associated with fluid needs that amount of bleeding that occurs. Blood will determine the amount of fluid replacement.
Assess: various bleeding / blood spending way to determine the location of bleeding and the type of a ruptured blood vessel. Bleeding that occurs suddenly, the color of fresh red blood, as well as continuous discharge describe bleeding that occurs in the upper gastrointestinal tract and ruptured arteries. If the emergency phase is over, the next phase of doing an assessment of:
3. Nutrition
Assess:
4. Temperature
Clients with hematemesis and melena generally increased temperatures around 38-39 degrees Celsius. In the state before the shock, skin temperature becomes cooler as a result of circulatory disorders. Stacking the rest of the bleeding is the source of infection in the digestive tract so that the client can increase the body temperature. In addition, long infusion can also be a source of infection that causes the body temperature to rise.
5. Elimination
On the client hematemesis and melena generally impaired elimination.
Assess:
6. Protection
Socio-economic background of the client, because the haematemesis and melaena need to do some enforcement action as diagnosis and therapy for clients.
Physiological Assessments
1. Oxygen
Assess:
- The number and color of blood hematemesis.
- Brownish color: blood from the stomach may still lagging behind, potential aspirations.
- Sleeping position: to prevent vomiting into the airway, preventing shock.
- Signs of shock: can occur when blood counts more than 500 cc and occurs continuously.
2. Fluids
Circumstances which need to be assessed on the client with hematemesis and melena associated with fluid needs that amount of bleeding that occurs. Blood will determine the amount of fluid replacement.
Assess: various bleeding / blood spending way to determine the location of bleeding and the type of a ruptured blood vessel. Bleeding that occurs suddenly, the color of fresh red blood, as well as continuous discharge describe bleeding that occurs in the upper gastrointestinal tract and ruptured arteries. If the emergency phase is over, the next phase of doing an assessment of:
- Balance intake - output. This assessment is done on the client hematemesis and melena caused by rupture of esophageal varices as a result of cirrochis liver, which often have ascites and edema.
- Intravenous fluids given to the client.
- Urine output and record numbers per 24 hours.
- Signs of dehydration such as decreased skin turgor, sunken eyes, the amount of urine. For clients with hemetemesis and melena often impaired renal function.
3. Nutrition
Assess:
- The client's ability to adapt to the diet: the first 3 days of liquid, then soft foods.
- Client's diet.
- Weight before bleeding.
- Oral hygiene: because hemetemesis and melena, remnants of bleeding can be a source of infection that cause discomfort.
4. Temperature
Clients with hematemesis and melena generally increased temperatures around 38-39 degrees Celsius. In the state before the shock, skin temperature becomes cooler as a result of circulatory disorders. Stacking the rest of the bleeding is the source of infection in the digestive tract so that the client can increase the body temperature. In addition, long infusion can also be a source of infection that causes the body temperature to rise.
5. Elimination
On the client hematemesis and melena generally impaired elimination.
Assess:
- Amount and how expenses, due to impaired renal function. Reduced urine and usually do care bed rest.
- Defecation, it is worth noting the number, color and consistency.
6. Protection
Socio-economic background of the client, because the haematemesis and melaena need to do some enforcement action as diagnosis and therapy for clients.
