Which of the following measures should the nurse focus on for the client with esophageal varices?
A. Recognizing hemorrhage.
B. Controlling blood pressure.
C. Encouraging nutritional intake.
D. Teaching the client about varices.
Correct Answer: A. Recognizing hemorrhage.
Recognizing the rupture of esophageal varices, or hemorrhage is the focus of nursing care because the client could succumb to this quickly. A patient with bleeding esophageal varices is to be considered in critical condition. Nursing management is aimed at assisting the physician in controlling bleeding and preventing shock and death.
Option B: Controlling blood pressure is also important because it helps reduce the risk of variceal rupture. As portal pressure increases, blood backs up into the spleen and bypasses the liver, returning to the right atrium via collateral circulation. The result is splenomegaly, ascites, and varicosities of the collateral veins (esophageal and gastric varices).
Option C: It is also important to teach the client what foods he should avoid such as spicy foods. Additional teaching includes abstaining from alcohol, eating a healthy diet, and adhering to short-term antibiotic therapy to prevent infection. Because rebleeding is common.
Option D: It is also important to teach the client what varices are. Assess for ecchymosis, epistaxis, petechiae, and bleeding gums. Monitor level of consciousness, vital signs, and urinary output to evaluate fluid balance. Use small-gauge needles, and apply pressure or cold for bleeding.
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