Goal: After nursing actions, balanced electrolyte fluid volume
Expected outcomes:
- Showed improved fluid balance, evidenced by adequate urine output with normal specific gravity.
- Vital signs are stable.
- Moist mucous membranes, good turgor and capillary refill quickly.
1. Monitor vital signs: compare with previous results.
Rationale: Changes in blood pressure and pulse can be used for a rough estimate blood loss.
2. Note the individual patient's physiological response to hemorrhage such mental changes, weakness, restlessness, anxiety, pallor, increased temperature and sweating.
Rational: symptomatology can be useful in measuring the weight / length episodes of bleeding, worsening of symptoms can indicate bleeding or inadequate understanding of the fluid.
3. Measure CVP when there
Rationale: Shows the circulating volume and cardiac responses to hemorrhage and fluid replacement, for example, CVP between 5 and 20 cm H2O showed adequate volume.
4. Supervise the input and output, and relationship to changes in weight, measuring blood loss / fluid through vomiting and defecation.
5. Maintain accurate records subtotal fluid / blood during replacement therapy.
Rationale: Potential excess fluid transfusion up, especially when the extra volume of blood transfusions given before.
6. Maintain bed rest: prevents vomiting and defecation current voltage.
Rationale: Activities / vomiting increased intra-abdominal pressure and can trigger bleeding continued.
7. Observations of secondary hemorrhage, such as nose / gum bleeding continuously from the area of injection.
Rationale: Loss / inadequate replacement clotting factors can trigger the occurrence of KID.
8. Give fluid / blood as indicated.
Rationale: Fluid replacement depends on the degree of hypovolemia and length of bleeding.
9. Full of fresh blood / red cell packaging
Rational: full of fresh blood indicated for acute bleeding (with shock), due to deficiency of blood clotting factors deposits.
10. Fresh frozen plasma (FFP) and / or platelets
Rational: coagulation factors / components decimation by 2 mechanisms: loss of bleeding and clotting.
11. Record intake and output
Rationale: Measuring inputs and expenditures can see fluid volume deficit occurs.
12. Check the hemoglobin, hematocrit, platelets every 4-6 hours
Rational: Seeing bleeding conditions change.
