1. Esophageal varices: life-threatening hemorrhage from tortuous dilated, thin-walled veins in submucosa of lower esophagus. May rupture when chemically or mechanically irritated or when pressure is increased because of sneezing, coughing, use of the Valsalva maneuver, or excessive exercise.
   1. Pathophysiology: portal hypertension related to cirrhosis of the liver —> distended branches of the azygos vein and inferior vena cava where they join the smaller vessels of the esophagus.
   2. Risk factors for hemorrhage:
      1. Exertion that increases abdominal pressure.
      2. Trauma from ingestion of coarse foods.
      3. Acid pepsin erosion.
   3. Assessment:
      1. Subjective data:
         1. Fear.
         2. Dysphagia.
         3. History: alcohol ingestion, liver dysfunction.
      2. Objective data:
         1. Hematemesis.
         2. Hemorrhage: sudden, often fatal.
         3. Decreased BP; increased pulse, respirations.
         4. Melena (occult blood in stool).
   4. Analysis/nursing diagnosis:
      1. Fluid volume deficit related to blood loss.
      2. Risk for injury related to hemorrhage.
      3. Fear related to massive blood loss.
      4. Ineffective individual coping related to complications of cirrhosis.
   5. Nursing care plan/implementation:
      1. Goal: provide safety measures related to hemorrhage.
         1. Recognize signs of shock; vitals q!5min.
         2. Assist with insertion of SengstakenBlakemore (or Minnesota) or Linton tube (tube is large and uncomfortable for patient during insertion); explain procedure briefly to decrease fear and attempt to gain patient’s cooperation.
         3. While tube is in place, observe for respiratory distress; if present, deflate the balloon by releasing pressure; do not cut the tube.
         4. Deflate the balloon as ordered to prevent necrosis.
         5. NG tube to low gastric suction; monitor for amount of bright-red blood; irrigate only as ordered using tepid, not iced, solutions.
         6. Vitamin K as ordered to control bleeding.
      2. Goal: promote fluid balance.
         1. IV fluids, expanders, blood.
         2. Fresh blood as ordered to avoid increased ammonia; aids in coagulation.
      3. Goal: prevent complications of hepatic coma.
         1. Saline cathartics as ordered to remove old blood from GI tract.
         2. Antibiotics as ordered to prevent infection.
         3. Reduce portal hypertension; give propranolol (Inderal), vasopressin (Pitressin).
      4. Goal: provide emotional support.
         1. Stay with patient.
         2. Calm atmosphere.
      5. Goal: health teaching.
         1. Explain use of tube to patient and family, b. Bland diet instructions.
         2. Recognize signs of bleeding.
         3. Avoid straining at stool.
         4. Avoid aspirin because of increased bleeding tendency.
   6. Evaluation/outcome criteria:
      1. Survives acute bleeding episode.
      2. Further episodes prevented by avoiding irritants, especially alcohol.
      3. Improves nutritional status.
      4. Recognizes symptoms of complications, e.g., bleeding.
      5. Demonstrates knowledge of medications by avoiding aspirin.