Question

B.B. is a 55-year-old Native American man admitted with a diagnosis of end-stage liver disease due to cirrhosis. He was diagnosed 12 years ago and acknowledges that he had drunk heavily for 20 years, but has now been sober for 2 years. He has complaints of anorexia, nausea, and abdominal discomfort. On physical exam, he is thin and malnourished with moderate ascites. Skin and sclera are jaundiced. He has 4+ pitting edema up to his mid-thigh. The liver and spleen are palpable. He has had one episode of bloody sputum.

What nursing diagnoses and interventions does this brief story suggest?

What assessments indicate a transfer to ICU?

Answer 1

1 Imbalanced nutrition less than body requirements,relatedto abdominal distension and discomfort and anorexia.

Nursing interventions

• Assess dietary intake and nutritional status through diet history and diary ,daily weight measurements and laboratory data.
• Provide diet high in carbohydrate with protein intake consistent with liver function.
• Assist patient in identifying low-sodium foods
• Elevate the head of the bed during meals.

b Fluid volume excess related to ascites and edema formation.

• Restrict sodium and fluid intake if prescribed.
• Administer diuretics,potassium,and protein supplements as prescrbed.
• Record intake and output every 1 to 8 hour depending on response to interventions and on patient acquity.
• Measure and record abdominal girth and weight daily.

2 The patient is at increased risk for bleeding and haemorrhage because of decreased production of prothrombin and decreased ability of the diseased liver to synthesize the necessary substances for blood coagulation.The nurse rherefore need to closely observe the patient for malena , and assesses stools for blood.Vital signs are monitored regularly.precautions are taken to minimize rupture of esophageal varices by avoiding further increase in portal pressure.if there is symptoms of gastrointestinal bleeding patien will be immediately transferred to ICU.