Question

Mr. W. is a 58-year-old male admitted to the critical care unit with a diagnosis of cirrhosis. Mr. W. has been experiencing nausea and vomiting for the past 5 days, shortness of breath, and low-grade fever. The morning of admission, he had an episode of passing bright red stools.

Mr. W. is drowsy but responsive to both verbal and painful stimuli. His wife stated that he had not been eating well and had difficulty sleeping for several nights.

On assessment, Mr. W.'s vital signs are oral temperature 100.5° F, blood pressure 105/60 mm Hg, pulse 102 beats/min, respirations 28/min, and oxygen saturation (SpO₂) 94% on 2 liters/min by nasal cannula. Lying supine, his SpO₂ dropped to 88%.

Mr. W. also has severe abdominal distention, is positive for jaundice, and has flapping tremors on his right hand. His past medical history includes alcohol (ETOH) dependency, hepatitis C, upper gastrointestinal bleeding, hypertension, and depression. Mr. W.'s initial laboratory results are as follows:

Sodium – 136 mEq/L
Potassium – 3.2 mEq/L
Blood urea nitrogen (BUN) – 28 mg/dL
Creatinine – 1.4 mg/dL
Bilirubin – 3.3 mg/dL
Platelets – 80,000 cells/microliter
Prothrombin time (PT) – 14 sec
Partial thromboplastin time (PTT) – 35.6 sec
Ammonia – 62 mcg/dL
Glucose – 75 mg/dL
White blood cell count – 11,000/microliter
Hemoglobin (Hgb) – 9.1 g/dL
Hematocrit (Hct) – 28.4%
Albumin – 3.0 g/dL

• What are the possible nursing diagnoses and interventions for Mr. W.?

Answer 1

patients diagnosis can be hepatic encephalopathy, because flapping tremor is a major sign and along with cirrohsis.

nursing diagnosis are:-

1.imbalanced nutrition less than body requirements

2. ineffective breathing pattern related to hypoxia

3. hyperthermia

4. excess fluid volume

5. risk for impaired skin integrity

6. risk for injury

nursing interventions are:-

monitor for any sigs of shock

manage hyperthermia by providing tepid sponge, antipyretics as ordered.

monitor vital sign every hourly

administer oxygen

hydrate and give nutritional suppliments and correct pottassium and sodium.

give foot end elevation, check for pitting edema.

respiratory assessments to be done

protect patients skin by providing skin care

moisturize skin, protect body prominents by providing support

position change every 2 hourly

assist in daily activities and routine care

strict intake output chart and fluid minitoring.

protect from any injuries like fall