Primary Nursing Diagnosis

Airway clearance, ineffective, related to aspiration of blood

OUTCOMES. Respiratory status: Gas exchange and ventilation; Safety status: Physical injury

INTERVENTIONS. Airway insertion; Airway management; Airway suctioning; Oral health promotion; Respiratory monitoring; Ventilation assistance; Surveillance; Respiratory monitoring; Anxiety reduction


Bleeding often subsides spontaneously, but if it does not, a Sengstaken-Blakemore or Minnesota tube is inserted to provide pressure at the source of bleeding by using a balloon tamponade. For continued bleeding, a nasogastric tube may be placed and connected to continuous low suction with periodic lavages. Intra-arterial infusion of vasopressin or therapeutic embolization into the left gastric artery during arteriography has also been shown to be effective in controlling bleeding in some patients. Other strategies to halt bleeding include endoscopy with electrocoagulation for hemostasis or transcatheter embolization with an autologous blood clot or artificial material, such as a gelatin sponge. On rare occasions, the patient may require surgery to suture the laceration.

If the patient has excessive blood loss, institute strategies to support the circulation. To stabilize the circulation and replace vascular volume, place a large-bore (14- to 18-gauge) intravenous catheter and maintain replacement fluids such as 0.9% sodium chloride and blood component therapy as prescribed. With continued or massive bleeding, the patient may be supported with blood transfusions and admitted to an intensive care unit for close observation.

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