Page 1500 - Saunders Comprehensive Review For NCLEX-RN

1. Hematemesis
2. Melena
3. Ascites
4. Jaundice
5. Hepatomegaly and splenomegaly
6. Dilated abdominal veins
7. Signs of shock

Rupture and resultant hemorrhage of esophageal varices is

the primary concern, because it is a life-threatening situation.
C. Interventions

1. Monitor vital signs.
2. Elevate the head of the bed.
3. Monitor for orthostatic hypotension.
4. Monitor lung sounds and for the presence of
repiratory distress.
5. Administer oxygen as prescribed to prevent tissue
hypoxia.
6. Monitor level of consciousness.
7. Maintain NPO status.
8. Administer fluids intravenously as prescribed to
restore fluid volume and electrolyte imbalances;
monitor intake and output.
9. Monitor hemoglobin and hematocrit values and
coagulation factors.
10. Administer blood transfusions or clotting factors as
prescribed.
11. Assist in inserting an NG tube or a balloon tamponade
as prescribed; balloon tamponade is not used
frequently because it is very uncomfortable for the
client and its use is associated with complications.
12. Prepare to assist with administering medications to
induce vasoconstriction and reduce bleeding.
13. Instruct the client to avoid activities that will initiate
vasovagal responses.
14. Prepare the client for endoscopic procedures or
surgical procedures as prescribed.
D. Endoscopic injection (sclerotherapy)
1. The procedure involves the injection of a sclerosing
agent into and around bleeding varices.
2. Complications include chest pain, pleural effusion,
aspiration pneumonia, esophageal stricture, and
perforation of the esophagus.
E. Endoscopic variceal ligation
1. The procedure involves ligation of the varices with an

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