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PLANNING/IMPLEMENTATION/EVALUATION

Pt. Room: _______

(Include a RUBRIC for each)

Nursing Diagnosis ___Excess fluid volume R/T decreased pr. and portal HTN aeb anasarca. Long Term Goal __Pt will regain optimal fluid volume status.__ Interventions
Support 1 action with EBP documented on the NPG

Date of clinical: __3/15-3/16______ Rationale 1. Pt has cirrhosis of the


liver which is a chronic, progressive disease that causes fibrosis and thus, decreased liver function. A major complication of cirrhosis is portal HTN, which is increased venous pressure in portal circulation caused by structural changes to the liver and subsequent compression and destruction of the portal veins and sinusoids. Portal HTN causes a protein shift from blood vessels, into the lymph space. When the lymph space is unable to rid the body of excess fluids, it leaks through the liver capsule and into the peritoneal cavity. Decreased protein in the blood causes additional fluid to be drawn into the peritoneal cavity due to

Outcome Criteria 1. Pts VS will remain


Pulse 60-100bpm Resp 12-20/min Temp 96.4-98.5F BP 90/60-120/80 As assessed Q4hrs.

1. Assess VS Q4hrs.

Evaluation M= met; P= partially met; U = unmet What did you do about any PM or U 1. P. Pts VS remained within these
limits except for BP. Pts BP has been increased. Pt has a Hx of HTN. Pt is receiving Furosemide daily, which is lowering her BP, but it still remains higher than given range. Continue to administer Furosemide Daily per MD order. Assess fluid volume status and BP to evaluate effectiveness of medication and to prevent any adverse S/Es such as hypotension. Plan is ongoing until D/C.

oncotic pressure. This results in ascites and anasarca. This can lead to decreased CO because the fluid is leaving the blood vessels and going into the interstitial spaces, thus causing a decrease in circulating blood volume. This decreased CO (decreased circulating volume) can result in decreased BP, which can lead to tissue hypoxia, due to a decrease in circulating O2. Tissue hypoxia can then lead to tachycardia and tachypnea, as the body attempts to compensate for the hypoxia. Pt is also receiving Furosemide Qday. Furosemide is a loop diuretic, which is being administered to help rid her body of excess fluid, thus decreasing her ansarca, but it can also lower her BP as it also decreases the fluid in her blood vessels. Assess VS Q4hrs to assess for any complications. (Lewis, NDHB)

2. Pt has cirrhosis, which


can lead to portal HTN. Portal HTN causes a protein shift from the vascular space into the

2. M. Pt remained A&O AATs and had

2. Pt will remain A&O


AATs.

2. Assess LOC Qhourly


rounds.

interstitial spaces. Decreased protein in the vascular space causes fluid to also be drawn into the interstitial spaces due to oncotic pressure. This results in a decreased circulating blood volume which causes a decreased ability of the blood to carry O2. Thus this can result is cerebral tissue hypoxia. Assess pt for change in LOC, restlessness, anxiety, and/or confusion. Pt also has a Hx of hepatic encephalopathy which is a neuropsychiatric manifestation of liver damage. Hepatic encephalopathy can occur due to the liver damage, which decreases the livers ability to convert ammonia into urea. (The urea would normally be excreted out of the body by the kidneys.) Thus the ammonia level in the systemic circulation rises and it crosses the bloodbrain barrier and can produce toxic neurologic manifestations. These manifestations may include a change in neurologic and mental responsiveness (confusion). Pt already has an increased

no change in her LOC as assessed Qhr. Plan is ongoing until D/C.

ammonia level (137), so safety is an issue. Assess for this changes and ammonia level per MD ordered labs. (Lewis, NDHB)

3. Pt has cirrhosis and


portal HTN which is causing a protein shift from the vascular space into the interstitial space. Due to decreased protein in the vascular space, oncotic pressure is causing fluid to follow the protein into the interstitial spaces, which is causing ascites and anasarca. Daily weights are the best indicator of fluid volume status. Pt is receiving Furosemide Qday. Furosemide is a loop diuretic and will cause an increase in diuresis. Thus after administration of furosemide, pt should have an increased U/O, which will cause a decrease in her FVE, and a decrease in her weight. Weigh pt QAM at 0600, on the same scale, in the same clothes to get the most accurate weight. Any weight gain indicates an increase in fluid volume status and should be reported to the MD. (NDHB, Lewis).

3. M. Pts weight on admission was


80kg (175lbs) and has decreased to 75kg (165lbs), when weighed on 3/16. So pt has lost a total of 10lbs since admission, which is equal to roughly 4.5L of fluid. Plan is ongoing until D/C.

3. Pt will lose 2.2lbs in


2days after Furosemide administration.

3. Weigh Qday at 0600.

4. Pt has cirrhosis of the


liver, which has progressed to portal HTN. This causes a protein shift from the vascular to the interstitial spaces. Decreased protein in the vascular space then causes fluid to also follow the protein into the interstitial spaces due to oncotic pressure. In the lungs this causes pulmonary vascular congestion and subsequent pulmonary edema. The fluids in the lungs also shift from the vascular space to the interstitial space, thus filling the tissues of the lungs and the alveoli. Build up of fluid in the lung tissues can cause a decreased ability for the lungs to expand. This along with fluid in the alveoli can cause a decreased O2 exchange. Upon auscultation, fine crackles will be heard in the lung fields. Furosemide, a loop diuretic is administered to the pt Qday, to help rid the pts body (and lungs) of this excess fluid. Auscultate the LS Q4hrs to identify any adventious LS and to assess the effectiveness of the

4. U. Pt has fine crackles in the bases


of her lungs R>L. Continue to administer diuretic per MD order. Assess LS Q4hrs and PRN. Keep HOB>/= 30degrees and provide supplemental O2 per MD order to ensure O2 sat>92%. Teach/encourage pt to TCDB to prevent atelectasis. Plan is ongoing until D/C.

4. Pts LS will trend from


fine crackles to clear after first dose of Furosemide administration.

4. Auscultate LS Q4hrs.

5. Pts labs will remain:


Albumin 3.5-5g/dL Tprotein 6.4-8.3g/dL As assessed per MD ordered labs.

5. Assess albumin/Tprotein
per MD ordered labs.

6. Pt will consume no

6. Ensure MD ordered

medication.. (NDHB, Lewis) 5. Pt has cirrhosis of the liver and the common complication portal HTN. Portal HTN causes a protein shift from the vascular to interstitial spaces. This protein shift causes fluid to follow into the interstitial spaces due to oncotic pressure. By assessing these labs, I can see if the serum albumin is increasing back into the stable range of 3.5-5g/dL. An increase in serum albumin will cause fluids to shift back into the vascular space which will help to decrease pts anasarca. (NDHB, Lewis) 6. Pt has cirrhosis and the common complication portal HTN, which is causing a protein shift from the vascular space into the interstitial spaces. This in turn causes fluids to follow the protein into the interstitial spaces due to oncotic pressure. Management of this is focused on sodium restricition. By limiting sodium to 2g/day, it will help to decrease fluid retention in the body (where salt goes/fluids follow). This restricted

5. U. Pts last lab was on 3/13 and


albumin was decreased at 2.8g/dL and Tprotein was also decreased at 5.8g/dL. Pts next ordered labs for albumin and Tprotein are 3/17. Until results of these labs are known, continue with MD ordered diuretics and offer high protein, low sodium snacks frequently throughout the day. Plan is ongoing until D/C.

6. M. Pt is on strict low sodium/2gram


diet per day. This is an MD ordered diet. As of now, pts anasarca has yet to improve. Restricted sodium diet will continue. Plan is ongoing

more than 2grams of sodium/day.

2gsodium diet.

7. Pts U/O will be at least


1L Qday after Furosemide administration.

7. Administer Furosemide
40mg PO BID.

sodium diet will either help decrease anasarca or at least not let it get any greater. (NDHB, Lewis) 7. Pt has cirrhosis of the liver and the common complication portal HTN. This has caused the pt to develop anasarca due to the protein/fluid shift from the vascular to the interstitial spaces. Furosemide is a high potency loop diuretic and is frequently used in the management of FVE. Furosemide inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubules. This increases the excretion of H2O and electrolytes from the body. 1 liter is equal to 1kg and 1kg is equal to 2.2lbs, which we would expect the pt to lose per day. This increased diuresis will help the body rid itself of excess fluid and will help decrease anasarca. (NDBH, Lewis, Daviss).

until D/C.

7. P. Pt had adequate U/O on 3/151000mL, but on 3/16 the total amount could not be measured because pt was incontinent. She did void 30mL prior to the foley being D/Cd, but after her other 2 voids could not be measured. Furosemide was switched per MD order from Furosemide 20mg IVP Q8hr to Furosemide 40mg PO BID on 3/16. MD changed the order due to pts exceptional diuresis and increased health status, yet with the D/Cing of the foley and pts incontinence, exact measurement of U/O was not feasible. Pt needs to be brought to the bathroom at least Q2hrs due to incontinence. Placing a nuns cap in the toilet will ensure that the U/O will be more accurately measured. Plan is

8. Pt has FVE and


anasarca due to portal HTN a common complication of cirrhosis. This anasarca is caused by a protein shift from the vascular to interstitial

8. Pt will verbalize 3 S/S of


FVE (SOB, clothes/shoes being tight, H/A) and 3 S/S of FVD (dry skin/mouth, excessive thirst, clothes/shoes being too big or looser than normal) after one teaching session today.

8. Teach S/S of FVE/FVD in


1 session.

spaces, in which fluid follows due to oncotic pressure. Due to the pts aggressive Tx, her fluid volume status can change rapidly. By teaching the pt these simple, easy to learn S/S of both FVE and FVD, the pt can identify a potential problem before it becomes too great and can alert staff at NBH, the assisted living facility that she resides at. This will also allow the pt to feel like she is more in control of her own wellbeing, which can help improve her moral. (NDHB, Lewis)

ongoing until D/C.

8. Pt listened to me explain about


FVE and S/S of FVE, but was only able to state that swelling was a S/S. FVD was not taught. Teaching needs to be done about both FVE and FVD, in simple terms that the pt can understand. By being able to recognize these simple S/S of fluid volume imbalance, the pt can then alert the medical staff at NBH, where she resides. Plan is ongoing until D/C.

9. Since pt lives in an
assisted living facility, it is important that the staff that care for her are aware that she needs to be weighed daily. Upon D/C teach the staff that daily weights for the pt are important because pt has cirrhosis of the liver and the common complication portal HTN. Teach staff that portal HTN causes a fluid shift out of the vascular system and into the surrounding tissues. Teach staff that daily weights will help determine if the pts

9. U. Pt was still admitted to the


hospital at the end of this clinical.

9. Staff member at NBH


will verbalize why it is important that pt be weighed daily per D/C instructions.

Collaborate 9. Prepare D/C instructions for NBH staff.

anasarca is decreasing or increasing. Teach staff that a weight gain of 2.2lbs in 2 days is critical and that the HCP must be informed of this. Teach staff to weight pt QAM, at the same time, on the same scale, and in the same clothes to get an accurate reading. Have staff verbalize this back to you, so that they clearly understand the necessity of this and why it is so important. If unable to verbally speak to staff, a phone call could be placed to relay this information and all the information should be written clearly in D/C instructions that would be presented to staff at NBH, upon pts return.

Ideally, if I were the RN for this pt, I would present this info to the staff at NBH (ideally the nursing staff). I would have the information written clearly on the D/C instructions and I would speak to a staff member at NBH to ensure that they understood that this should be done daily and why it should be done daily. I hope that some type of communication happened between the two facilities and that this information was relayed. Plan is ongoing until D/C.

10.

Pt lives at NBH, which will provide her with all her meals, but pt may still be able to pick her own snacks out, or may have family bring her in snacks. By teaching the pt what snacks to avoid, the pt will be able to pick healthier, lows sodium snacks that will not contribute to her anasarca. This may also empower the pt and make her feel more in

10.

10.

Pt will verbalize 3 unhealthy snacks for 2g/sodium diet in one teaching session today.

Teach high sodium snacks to avoid in 1session.

charge of her own health. Teach the pt to avoid high sodium foods such as, salted nuts, potato chips, salted crackers, pickles, cheeses, and carbonated sodas. Teach pt that these snacks have a high sodium content which can cause her to have increased swelling (anasarca) in her body. Teach pt that where sodium goes, fluid goes and thats why she may feel bloated after eating salty foods. Teach pt that if she has the option to always pick unsalted snacks vs. salted ones. Teach pt using simple and clear communication that the pt can understand. Have pt verbalize understanding and list at least 3 unhealthy snacks to avoid. (Lewis)

10.

U. This was not taught to the pt. In order to meet this outcome the pts knowledge of her condition should be evaluated and a teaching plan should be conducted in a manner that she can understand. Have pt verbalize understanding and list unhealthy foods for her condition. Plan is ongoing until D/C.

11.

In order to help decrease the pts anasarca due to portal HTN, the pt should be provided small, high protein snacks throughout the day. The portal HTN causes a protein shift into the interstitial spaces which causes fluid to follow. This causes a decreased serum albumin. By

11.

11.

Pt will consume >/= 40grams of protein/day.

Provide frequent high protein snacks throughout the day.

introducing more protein into the diet, it can be absorbed and help increase her low albumin levels. By increasing her low albumin level this will cause an increase in protein in her vascular space and help fluid shift back into the vascular space. Many high protein snacks are also high in sodium, which the pt should not eat. Thus, offer the pt high protein snacks that are low in sodium such as unprocessed meats and fish, eggs, fruits, veggies, unsalted nuts, dried beans, and nutritional supplements (snack bars or drinks). (Lewis)

11.

U. Pt was offered nutritional supplement drinks such as ensure, but often stated she did not have an appetite and did not drink them. Pt was not offered high protein snacks besides this. Pt should be offered frequent small protein snacks. Plan is ongoing until D/C.

12.

Pts PICC line must remain patent. In order for it to remain patent the PICC line needs to be flushed Qday, prior to IVP meds, and PRN. Flush PICC line with 10mL NS in 10mL syringe per ACH policy. Always alcohol 15/15 prior to flushing to avoid introducing an infection into the pt. When flushing, use a pulse like method while introducing the NS. This PICC needs to remain patent because the pt

12. 12.
PICC line will remain patent AATs.

Flush PICC with 10mL NS Qday.

was previously being administered Furosemide IVP, which was changed to PO on 3/16. If the MD decides that the PO administration is not getting the desired effects or the same effects as the IVP administration, the order may be changed back to IVP. Thus the PICC line needs to remain patent for future use to ensure that the pts anasarca will be treated, and to prevent the patient from having to have a new PICC site established.

12.

M. Pts PICC line remained patent. Continue to flush the PICC line Qday, prior to med administration, and PRN per ACH policy. Plan is ongoing until D/C.

13.

Maintain pts foley by ensuring that the cath outside of the pts body is cleaned properly, Qday. Ensure that the foley bag is placed on a nonmovable bed part below the level of the pts bladder. Ensure that the pts leg strap is correctly placed to decrease tension on the cath and decrease the possibility of it being accidently pulled out during movement, etc. Empty foley Qshift and PRN, always cleansing with alcohol prior, to avoid introducing bacteria into the foley. The foley for this pt is critical to help

determine the effectiveness of the daily Furosemide administration. The Furosemide increases diuresis, which will increase U/O, which will help to decrease pts anasarca, and help correct her FVE.

13.

M. Pts foley was maintained properly. It was D/Cd and removed on 3/16.

14. 13.
Qday. Maintain foley

13.

Pts foley will remain clean and intact Qday.

Pt has an order to ambulate 200ft Qday. Immobility can actually add to or increase edema in the legs. Ambulation will help to decrease the edema in the pts legs by increasing venous return, due to muscles actually pushing the fluid and blood, with the movement of ambulation. This will help to increase the circulation and help to move some of the excess fluid out of the pts lower extremities. Thus, this will help improve pts anasarca. This also will help perfuse the kidneys and other vital organs better due to an increase in circulation. Ambulate pt using a WW, portable O2 2L NC, and continuous observation.

14.

14.
Qday.

Ambulate 200ft

P. Pt was not walked on 3/15, but did walk 200ft on 3/16. Prior to 3/15 the pt stated she had only ambulated once. Pt needs to be ambulated Qday to help improve circulation and decrease anasarca. Plan is ongoing until D/C.

14.

Pt will ambulate 200ft Qday.

Outcome Criteria

Interventions

Rationale

Evaluation

Every outcome needs an intervention. Every outcome needs to be evaluated. Number each outcome, intervention, rational and evaluation. Included all interventions Independent (assess, monitor), Dependent, Collaborating and Teaching that apply to this patient.