Risk for Bleeding r/t decreased Vitamin K absorption Assessment Post hepatoduodenostomy surgery.

Nursing Diagnosis Risk for Bleeding r/t decreased Vitamin K absorption Rationale Vitamin K controls the formation of coagulation factors II (prothrombin), VII, IX, and X in the liver. Other coagulation factors dependent on vitamin K are protein C, protein S, and protein Z; proteins C and S are anticoagulants. Vitamin K deficiency decreases levels of prothrombin and other vitamin K dependent coagulation factors, causing defective coagulation and, potentially, bleeding. Objectives Be free of signs of bleeding on incision site and secondary bleeding from nose, gums, and ecchymoses. Nursing Interventions 1. Assess for signs and symptoms of GI bleeding. Check for secretions. Observe color and consistency of stool and vomitus. 2. Maintain on bed rest and prevent straining. Schedule activities to provide undisturbed rest periods. 3. Observe for presence of echymoses, bleeding in one or more sites. 4. Monitor Vital signs. BP and pulse. 5. Encourage use of soft bristled toothbrush, avoid straining for stool and forceful nose Rationale G.I tract is the most common source of bleeding due to its mucosal fragility. Evaluation

Activities and straining may predispose to further bleeding.

Clotting factors may be altered and cause easy bruising and bleeding. An increase in pulse rate and decrease in blood pressure may indicate loss of circulating blood volume. Minimal trauma can cause bleeding due to decreased clotting factors.

blowing. 6. Recommend avoidance of aspirin containing products.

Prolongs coagulation, potentiating risk of hemorrhage.