Question

Which nursing diagnosis should receive priority when the nurse is caring for a client with esophageal varices? A. Imbalanced nutrition: less than body requirements related to difficulty swallowing B. High risk for injury related to altered clotting mechanisms C. Fluid volume deficit related to reduced oral intake D. Activity intolerance related to fatigue

Short answer

Answer: B. High risk for injury related to altered clotting mechanisms.

Step-by-step solution

Analyze the options

Go through the four options given and determine their relevance to the key complication associated with esophageal varices: the risk of spontaneous rupture and bleeding. A. Imbalanced nutrition: less than body requirements related to difficulty swallowing - This diagnosis is related to the possibility of the client not getting enough nutrition due to difficulty swallowing, which can be a concern in some cases. However, it is not directly related to the key complication of bleeding. B. High risk for injury related to altered clotting mechanisms - This diagnosis is directly related to bleeding and the risk of spontaneous rupture. C. Fluid volume deficit related to reduced oral intake - This diagnosis addresses the client's risk of not getting enough fluids due to reduced oral intake. However, it is not directly related to the key complication of bleeding. D. Activity intolerance related to fatigue - This diagnosis is related to the client's ability to perform daily activities due to fatigue. However, it is not directly related to the key complication of bleeding.

Prioritize based on the key complication

Since the most significant complication of esophageal varices is the risk of spontaneous rupture and bleeding, the priority nursing diagnosis should be the one that is directly related to this key complication. Based on the analysis of the options, option B (High risk for injury related to altered clotting mechanisms) is directly related to the bleeding risk.

Choose the priority nursing diagnosis

Based on the above analysis, we can now determine the priority nursing diagnosis for a client with esophageal varices: B. High risk for injury related to altered clotting mechanisms.

Key concepts

Nursing Care Priorities

In caring for patients with esophageal varices, nurses must prioritize interventions that address the most severe and life-threatening complications. Given the significant risk of bleeding associated with esophageal varices, the primary focus is on monitoring and preventing bleeding episodes. Nursing care priorities include:

• Regular monitoring of vital signs to detect early signs of bleeding.
• Assessing for any signs of hemorrhage, such as hematemesis (vomiting blood) or melena (black, tarry stools).
• Maintenance of IV access to administer fluids and medications promptly in case of bleeding.
• Ensuring patient safety by implementing fall precautions due to potential dizziness or weakness.
• Education about the avoidance of activities and medications that can increase bleeding risk, such as the use of NSAIDs or heavy lifting.

Early detection and intervention are critical in managing this condition and can make a significant difference in patient outcomes.

Risk for Bleeding

Esophageal varices present a heightened risk for bleeding due to the fragile nature of the dilated veins within the esophagus. These vessels have a high potential to rupture and cause significant blood loss. The risk for bleeding can be exacerbated by numerous factors, such as increased abdominal pressure from coughing, straining, or vomiting, or from erosive damage by ingested substances.

To mitigate this risk, nursing interventions center around:

• Monitoring for early signs of blood loss such as decreasing blood pressure and increasing heart rate.
• Providing education on avoiding straining during bowel movements and seeking immediate help if signs of bleeding occur.
• Advising against the consumption of alcohol and spicy foods that may irritate the esophageal lining.

Esophageal Varices Complications

Complications from esophageal varices primarily arise from their potential to rupture, leading to life-threatening hemorrhage. Additionally, the formation of clots within the varices can cause further complications if they dislodge and travel to other parts of the body.

Complications can include:

• Massive hematemesis leading to hypovolemic shock.
• Aspiration pneumonia caused by inhaling blood.
• Development of hepatic encephalopathy as a result of increased ammonia levels due to decreased liver function.
• Iron deficiency anemia from chronic blood loss.

Effective management involves prompt endoscopic interventions, like band ligation or sclerotherapy, to control bleeding and prevent recurrence.

Altered Clotting Mechanisms

Patients with esophageal varices often have underlying liver diseases—most commonly cirrhosis—which impairs the liver's ability to synthesize coagulation factors. This altered clotting mechanism increases the risk of both bleeding and clotting complications.

Nursing strategies focused on altered clotting mechanisms include:

• Administering prescribed vitamin K or blood products to improve clotting factors.
• Continuous assessment of laboratory values, specifically prothrombin time (PT) and international normalized ratio (INR), to monitor coagulation status.
• Educating patients about medications and foods that can affect clotting mechanisms.
• Engaging in collaboration with a multidisciplinary team for optimal management of the underlying liver condition.