Nursing Care Plan for Risk for Fluid Volume Deficit related to Hematemesis - Melena
Gastrointestinal tract bleeding is an emergency that requires immediate treatment. The incidence of gastrointestinal bleeding reached approximately 100 cases in 100,000 population per year, predominantly from the upper gastrointestinal tract.
Upper gastrointestinal bleeding appears 4 times more often than bleeding at the bottom, and is a major cause of morbidity and mortality in cases of gastrointestinal disorders. Mortality from upper gastrointestinal bleeding was found as much as 6-10% of all cases.
Gastrointestinal tract bleeding can occur in five types of manifestations, namely hematemesis, melena, hematochezia, occult GI bleeding which can be detected even though not found bleeding on stool examination, as well as signs of anemia such as syncope and dyspnea.
Hematemesis is vomiting blood. Blood can be in the form of fresh (clot or clots or bright red liquid) or changed due to enzymes and stomach acid, to brown and shaped like a coffee granules. Can hematemesis due to the injury or bleeding in the upper gastrointestinal tract.
Melena is black stool and stink because the product mix blood from the gastrointestinal tract. The presence of melena shows that blood has been in the gastrointestinal tract within at least 14 hours and usually occur in the upper gastrointestinal tract, although sometimes melena may also occur as a result of bleeding from the colon.
Nursing Diagnosis for Hematemesis - Melena : Risk for Fluid Volume Deficit related to bleeding
Subjective data:
Goal: fluid requirements are met.
Expected outcomes:
Interventions :
Rationale :
Upper gastrointestinal bleeding appears 4 times more often than bleeding at the bottom, and is a major cause of morbidity and mortality in cases of gastrointestinal disorders. Mortality from upper gastrointestinal bleeding was found as much as 6-10% of all cases.
Gastrointestinal tract bleeding can occur in five types of manifestations, namely hematemesis, melena, hematochezia, occult GI bleeding which can be detected even though not found bleeding on stool examination, as well as signs of anemia such as syncope and dyspnea.
Hematemesis is vomiting blood. Blood can be in the form of fresh (clot or clots or bright red liquid) or changed due to enzymes and stomach acid, to brown and shaped like a coffee granules. Can hematemesis due to the injury or bleeding in the upper gastrointestinal tract.
Melena is black stool and stink because the product mix blood from the gastrointestinal tract. The presence of melena shows that blood has been in the gastrointestinal tract within at least 14 hours and usually occur in the upper gastrointestinal tract, although sometimes melena may also occur as a result of bleeding from the colon.
Nursing Diagnosis for Hematemesis - Melena : Risk for Fluid Volume Deficit related to bleeding
Subjective data:
- The client fasting, thirst, frequent sweating.
- Mucosa dry mouth, vomiting blood often (3 times) in the hospital, dysentery mixed urinary maroon.
Goal: fluid requirements are met.
Expected outcomes:
- Vital signs within normal limits.
- Normal skin turgor.
- Mucous membranes moist.
- Urine production output balance.
- Blood vomiting and defecating blood stopped.
Interventions :
- Measure and record intake and expenditure.
- Monitor vital signs.
- Monitor parenteral fluids.
- Monitor the laboratory; Hb, Hct.
Rationale :
- Accurate documentation helps to identify the loss of fluid or fluid needs and affect subsequent action.
- Hypotension, tachycardia, increased respiration is an indication of lack of fluids.
- Excessive bleeding can cause hipovelemia, circulatory collapse.
- Volume depletion petensial for dehydration, cardiovascular collapse, fluid and electrolyte imbalance.
- Anemia, low HCT occurs due to fluid loss during blood vomiting and defecating blood.
