Copyright 2014, 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983 by Mosby, an imprint of Elsevier Inc.Copyright 2014, 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983 by Mosby, an imprint of Elsevier Inc.eNURSING CARE PLAN 44-2

Patient With Cirrhosis

NURSING DIAGNOSIS*: Imbalanced nutrition: less than body requirements related to anorexia, impaired utilization and storage of nutrients, nausea, and loss of nutrients from vomiting as evidenced by lack of interest in food, aversion to eating, reported inadequate food intakeNURSING DIAGNOSIS: Impaired skin integrity related to peripheral edema, ascites, and pruritus as evidenced by complaints of itching; areas of excoriation due to scratching; taut, shiny skin over edematous areas; and/or areas of skin breakdown

PATIENT GOAL: Maintains skin integrity with relief of edema and pruritus

Outcomes (NOC)Interventions (NIC) and Rationales

Tissue Integrity: Skin and Mucous MembranesSkin integrity _____Elasticity _____Texture _____Hydration _____

Measurement Scale1 = Severely compromised2 = Substantially compromised3 = Moderately compromised4 = Mildly compromised5 = Not compromisedPruritus ManagementInstruct patient to keep fingernails trimmed short to prevent excoriation due to pruritus secondary to deposit of bile salts in skin.Apply medicated creams and lotions to relieve itching, avoiding use of systemic drugs that require liver metabolism.

Skin Care: Topical TreatmentsInspect skin daily for those at risk of breakdown because edematous tissues are easily traumatized and subject to breakdown.Provide support to edematous areas (e.g., pillows under arms and scrotal support).Turn the immobilized patient at least every 2 hr to reduce risk of skin breakdown in dependent areas.Keep bed linen clean, dry, and wrinkle free to protect skin from irritation.Refrain from using an alkaline soap on the skin to prevent additional irritation of the skin.

NURSING DIAGNOSIS: Excess fluid volume related to portal hypertension and hyperaldosteronism as evidenced by weight gain, dependent edema, ascites

PATIENT GOALS: Experiences normalization of fluid balance as a result of medical and nursing interventionsMaintains blood pressure and urinary output within normal limits

Outcomes (NOC)Interventions (NIC) and Rationales

Fluid Overload SeverityAscites _____Increased abdominal girth _____Generalized edema _____Increased blood pressure _____Increased body weight _____Decreased urinary output _____

Measurement Scale1 = Severe2 = Substantial3 = Moderate4 = Mild5 = None

Hypervolemia ManagementWeigh patient daily and monitor trends to evaluate effectiveness of treatment.Administer prescribed diuretics to prevent fluid retention and promote diuresis.Monitor intake and output to maintain necessary fluid restrictions and assess renal function.Monitor changes in peripheral edema to determine patients response to treatment.

Fluid/Electrolyte ManagementProvide prescribed diet appropriate for specific fluid or electrolyte imbalance (e.g., low-sodium, fluid-restricted, low-protein, and no added salt) to prevent additional fluid retention.Obtain laboratory specimens for monitoring of altered fluid or electrolyte levels (e.g., hematocrit, BUN, protein, sodium, and potassium levels) to evaluate effectiveness of treatment.

NURSING DIAGNOSIS: Ineffective self-health management related to ineffective coping and abuse of alcohol as evidenced by observed inability to take responsibility for health and failure to take action to reduce risk factors

PATIENT GOALS: Acknowledges a substance abuse problemParticipates in an alcohol treatment programAchieves abstinence of alcohol

Outcomes (NOC)Nursing Interventions and Rationales

Alcohol Abuse Cessation BehaviorsExpresses willingness to stop alcohol use _____Commits to alcohol elimination strategies _____Uses effective coping mechanisms _____Adjusts lifestyle to promote alcohol elimination _____Obtains assistance from health professional _____Uses available support groups _____

Measurement Scale1 = Never demonstrated2 = Rarely demonstrated3 = Sometimes demonstrated4 = Often demonstrated5 = Consistently demonstrated

Health Beliefs: Perceived ControlBelief that own decisions control health outcomes _____Belief that own actions control health outcomes _____Perceived responsibility for health decisions _____

Measurement Scale1 = Very weak2 = Weak3 = Moderate4 = Strong5 = Very strongSubstance Use TreatmentEncourage patient to take control over behavior to change undesired behaviors.Discuss with patient the impact of substance use on medical condition and general health to promote acknowledgment of consequences of use.Assist patient to learn alternative methods of coping with stress or emotional distress to reduce substance use.Identify support groups in the community for long-term substance abuse treatment to promote continued abstinence.

Self-Responsibility FacilitationHold patient responsible for own behavior to facilitate responsible behaviors.Discuss with patient the extent of responsibility for present health status.Discuss consequences of not dealing with own responsibilities to emphasize realistic outcomes.Set limits on manipulative behaviors to prevent attempts to shift responsibilities.Refrain from arguing or bargaining about the established limits with the patient to prevent avoidance of responsibility.Provide positive feedback for accepting additional responsibility and/or behavior change to reinforce desired behaviors.

NURSING DIAGNOSIS: Dysfunctional family processes related to abuse of alcohol and inadequate coping skills as evidenced by deterioration in family relationships, family denial, neglected obligations, inability to accept and receive help appropriately

PATIENT GOALS: Family confronts problems and involves family members in decision makingFamily uses available social support for treatment of alcohol abuse

Outcomes (NOC)Interventions (NIC) and Rationales

Family CopingConfronts family problems _____Uses strategies to manage family conflict _____Establishes family priorities _____Shares responsibility for family tasks _____Uses available family support system _____Involves family members in decision making _____

Measurement Scale1 = Never demonstrated2 = Rarely demonstrated3 = Sometimes demonstrated4 = Often demonstrated5 = Consistently demonstrated

Family TherapyDetermine family communication pattern to identify appropriate interventions.Identify family strengths/resources to determine appropriate interventions.Help members prioritize and select the most immediate family issue to address.Help family enhance existing positive coping strategies for use in promoting coping.Help family set goals toward a more competent way of handling dysfunctional behavior.Accept the familys values in a nonjudgmental manner.Monitor for adverse therapeutic responses in order to intervene as necessary.

COLLABORATIVE PROBLEMS

POTENTIAL COMPLICATION: Hemorrhage related to bleeding tendency secondary to altered clotting factors and rupture of esophageal or gastric varices

Nursing GoalsNursing Interventions and Rationales

Monitor for signs of hemorrhageInitiate appropriate medical and nursing interventions

Monitor for hemorrhage by assessing for epistaxis, purpura, petechiae, easy bruising, gingival bleeding, hematuria, heavy menstrual bleeding, melena, or frank bleeding from body orifices because liver disease results in impaired synthesis of clotting factors.Monitor circulatory status: BP, skin color, skin temperature, heart rate and rhythm, presence and quality of peripheral pulses, and capillary refill for early detection of hypovolemic shock.Provide gentle nursing care to minimize the risk of tissue trauma.Use smallest-gauge needle possible when giving injections or drawing blood specimens and apply gentle but prolonged pressure to injection sites to minimize risk of bleeding into tissue.Advise use of soft-bristle toothbrush and avoidance of irritating food to reduce injury to highly vascular mucous membranes.Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing to reduce risk of hemorrhage at these sites.Monitor laboratory results (hematocrit, hemoglobin, and prothrombin time) as indicators of anemia, active bleeding, or impending clotting problems.

POTENTIAL COMPLICATION: Hepatic encephalopathy related to increased serum levels of ammonia due to inability of liver to convert accumulating ammonia to urea for renal excretion

Nursing GoalsNursing Interventions and Rationales

Monitor for signs of hepatic encephalopathyReport deviation from acceptable parametersCarry out appropriate medical and nursing interventions

Monitor for encephalopathy (assess patients general behavior, orientation to time and place, speech, blood pH, and ammonia levels) caused by toxic effects of ammonia on nervous system.Encourage fluids (if not restricted) and administer medications as ordered to decrease ammonia production and absorption from the bowel and to promote bowel elimination of ammonia.Limit physical activity because exercise produces ammonia as a by-product of protein metabolism.

*Nursing diagnoses listed in order of priority.**Outcomes and interventions for this nursing diagnosis for the patient with cirrhosis are presented in eNCP 44-1,the Patient With Acute Viral Hepatitis.BUN, blood urea nitrogen.