Nursing Diagnosis

Fluid Volume Deficit (Isotonic)

Active volume loss (hemorrhage)

Objectives
Short term goal:
Client will be able to participate in
procedures and treatments
necessary for his assumption of
adequate fluid volume.

Defining characteristics: (Evidenced by)

Long term goal:

Possible Etiologies: (Related to)

Pallor
Cool, clammy skin
Restlessness/ changes in
mentation
Easy fatigability/ weakness
Apprehension
Diaphoresis
Hypotension, tachycardia,
delayed capillary refill
Oliguria
ECG changes
Syncope
Hemoconcentration

Client will be able to maintain

fluid volume at a functional level
as evidenced by clients adequate
urine output, stable vital signs,
prompt capillary refill, and
laboratory results of hemoglobin
and hematocrit within normal
range.

Nursing Interventions
1. Check for the appearance of
vomitus, stool, or drainage.
2. Monitor vital signs and compare
with clients normal and previous
data; you may take blood pressure in
different positions like when sitting,
lying, and standing positions as much
as possible.
3. Assess clients physiological
response to hemorrhage like
changes in mentation, weakness,
apprehension, diaphoresis,
restlessness, and anxiety.
4. Measure central venous pressure
if indicated and available.
5. Strictly monitor fluid intake and
output; measure fluid loss through
emesis, gastric drainage and stools.
6. Maintain client on bed rest to
prevent vomiting and straining when
defecation; schedule activities in
order to provide adequate rest for
the client.
7. Place client in fowlers position
during antacid gavage.

Rationale
- It helps in differentiating the cause
of gastric distress; bright red blood
may be caused by arterial bleeding;
dark red blood may be due to
esophageal bleeding; coffee ground
may be because of partly digested
blood from slowly oozing area.
- The alterations and fluctuations in
blood pressure may be used for
rough estimate of blood loss; BP
less than 90 mmHg may reflect a
25% volume loss.
- Worsening in symptomatology
may be due to continuous
hemorrhage or inadequate fluid
replacement.
- It reflects blood volume in the
body and cardiac response to
bleeding; It may reflect how
effective fluid replacement therapy.
- It gives the basis for fluid
replacement.
- Vomiting aggravates intraabdominal pressure and can
predispose to further bleeding.

- It prevents gastric reflux an

aspiration of medication.

8. Take note for any signs of

renewed bleeding after cessation of
initial bleeding.

- Rebleeding may sometimes occur

as evidenced by abdominal fullness,
nausea and vomiting.

9. Check for signs of secondary

bleeding i.e. nose or gums,
echymosis.

- These parameters to know how

adequate fluid replacement is;
symptoms given may cause DIC.

10. Maintain client on NPO as

- That is in order to prevent further

Evaluation
Client will be able to demonstrate
positive and accepting behaviours
with regards to treatment
interventions like nasogastric tube
insertion and blood transfusion
and as well participate during
necessary procedures like
endoscopy, 12 lead ECG,
abdominal X ray and laboratory
extractions.
Client will demonstrate adequate
and improved fluid balance as
evidenced by clients adequate
urine output (more than 30 cc
which reflects adequate intake)
with normal specific gravity, blood
pressure ranging from 110/70
mmHg to 120/80mmHg, pulse rate
ranging from 72 88 beats per
minute, capillary refill of less than
2 seconds, and laboratory results
showed adequate haemoglobin
and hematocrit levels within one
week of nursing care.

ordered by the physician.

gastric distress.

11. Resume intake with clear/ bland

fluids or as indicated by the
physician; avoid giving dark colored
foods.

- Foods easily digested reduce the

risk for added irritation; to take
note for possible rebleeding.

12. Administer IV fluids/ volume

expanders/ fresh whole
blood/platelet/fresh frozen plasma
as indicated.
13. Insert NGT as indicated by the
physician.

14. Perform gastric lavage with cool

saline solution until aspirate is
pinkish in color or if it is clear.
15. Administer medications like H2
receptors antagonists, antiulcer
agents, antacids, Vitamin K,
antiemetic, and anti infective.
16. Monitor laboratory findings like
hemoglobin, hematocrit, BUN and
creatinine.

- Fluid replacement is essential in

improving clients blood volume.

- It is an avenue for removing

gastric secretions, blood, and
clots; reduces vomiting and
facilitates endoscopy, if applied.
- It prevents further bleeding by
local vasoconstriction.

- These medications are essential in

treating client with acute GI
hemorrhage; they have their own
specific and actions regarding this
condition.
- It assists in knowing how much
blood replacement is needed;
BUN greater than 40 with normal
creatinine level reflects a major
bleeding.