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

1. What procedures and treatments would you anticipate for Mr. W.?

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

3. What would be considered a high-risk complication for Mr. W.?

Answer 1

1.Procedures:

• Band Ligation

Endoscopy, which consists of a narrow tube mounted with a video camera being inserted into the throat, is used to identify the bleeding site. A rubber band is used to tie off the bleeding portion of the vein.

• Transjugular Intrahepatic Portosystemic Shunting (TIPS)

The TIPS procedure is the creation of an artificial connection directly between the portal veins and hepatic veins of your liver. The entire procedure is performed using needles, catheters, wires, and stents placed through a vein in the neck.

• Paracentesis

simply takes fluid out from the abdominal cavity.In this procedure, a soft catheter is inserted into the abdomen. Usually when large volumes of fluid are to be removed, human albumin is introduced into the abdominal cavity.

Treatments:

• Low sodium diet and Avoid alcohol

• Medications;Diuretic, Ammonia reducer, Beta blocker, Antibiotics and Antiviral drug

• Surgery:Liver transplantation

2.Nursing diagnosis

1.Imbalanced nutrition less than body requirements related to anorexia, nausea/vomiting, indigestion, early satiety (ascites)

interventions:

Measure dietary intake by calorie count,Give small, frequent meals.Refer to dietitian to provide diet high in calories and simple carbohydrates, low in fat, and moderate to high in protein; limit sodium and fluid as necessary. Provide liquid supplements as indicated.

2.Ineffective breathing pattern related to Intra-abdominal fluid collection (ascites)

Monitor respiratory rate, depth, and effort.Keep head of bed elevated. Position on sides.Encourage frequent repositioning and deep-breathing exercises and coughing exercises.Monitor serial ABGs, pulse oximetry, vital capacity measurements, chest x-rays.Provide supplemental O₂ as indicated.

3.Excess Fluid Volume related to Compromised regulatory mechanism

Measure I&O, weigh daily, and note gain of more than 0.5 kg/day.Monitor BP (and CVP if available). Note JVD and abdominal vein distension.Measure abdominal girth.Restrict sodium and fluids as indicated.Administer Diuretics: spironolactone (Aldactone), furosemide (Lasix)

4.Disturbed Body Image related to biophysical changes/altered physical appearance

Discuss situation and encourage verbalization of fears and concerns. Explain relationship between nature of disease and symptoms.Encourage family/SO to verbalize feelings, visit freely and participate in care.Refer to support services. Counselors, psychiatric resources, social service, clery and alcohol treatment program may help.

3.High risk complication

Cirrhosis can result in portal hypertension and/or hepatic dysfunction. Both of these either alone or in combination can lead to many complications, including ascites, varices, hepatic encephalopathy, hepatocellular carcinoma, hepatopulmonary syndrome, and coagulation disorders.