Impaired skin integrity related to pruritus from jaundice and edema

GOAL: Decrease potential for pressure ulcer development; breaks in skin integrity
Expected Outcomes
Exhibits intact skin
without redness,excoriation,
or breakdown.
Reports relief from
pruritus.
Exhibits no skin
excoriation from scratching.
Uses nondrying soaps and
lotions.States rationale for
use of nondrying soaps and
lotions.
Turns self periodically.
Exhibits reduced edema of
dependent parts of the body.
Exhibits no areas of skin
breakdown.
Exhibits decreased edema;
normal skin turgor.

Nursing Interventions
1. Assess degree of
discomfort related to
pruritus and edema.
2. Note and record degree
of jaundice and extent of
edema.

Rationale
1. Assists in determining
appropriate interventions.

2. Provides baseline for

detecting changes and
evaluating effectiveness of
interventions.
3. Keep patients nger
3. Prevents skin excoriation
nails short and smooth.
and infection from
scratching.
4. Provide frequent skin
4. Removes waste products
care; avoid use of soaps and from skin while preventing
alcohol-based lotions.
dryness of skin.
5. Massage every 2 h with
5. Promotes mobilization of
emollients;turn every 2 h.
edema.
6. Initiate use of alternating- 6. Minimizes prolonged
pressure
pressure on bony
mattress or low air loss bed. prominences susceptible to
breakdown.
7. Recommend avoiding use 7. May decrease skin
of harsh detergents.
irritation and need for
scratching.
8. Assess skin integrity
8. Edematous skin and
every 48 h. Instruct patient tissue have compromised
and family in this activity.
nutrient supply and are
vulnerable to pressure and
trauma.
9. Restrict sodium as
9. Minimizes edema
prescribed.
formation.
10. Perform range of motion 10. Promotes mobilization
exercises every 4 h; elevate of edema.
edematous extremities
whenever possible.

Fluid volume excess related to ascites and edema formation

GOAL: Restoration of normal uid volume
Expected Outcomes
Consumes diet low in
sodium and within
prescribed uid restriction.
Takes diuretics, potassium,
and protein supplements as
indicated without
experiencing side effects.
Exhibits increased urine
output.
Exhibits decreasing
abdominal girth.
Exhibits no rapid increase
in weight.
Identies rationale for
sodium and uid restriction.
Shows a decrease in
ascites with decreased
weight.

Nursing Interventions
1. Restrict sodium and uid
intake if prescribed.
2. Administer diuretics,
potassium, and protein
supplements as prescribed.
3. Record intake and output
every 1 to 8 h depending on
response to interventions
and on patient acuity.
4. Measure and record
abdominal girth and weight
daily.
5. Explain rationale for
sodium and uid restriction.
6. Prepare patient and assist
with paracentesis.

Rationale
1. Minimizes formation of
ascites and edema.
2. Promotes excretion of
uid through the kidneys
and maintenance of normal
uid and electrolyte
balance.
3. Indicates effectiveness of
treatment and adequacy of
uid intake.
4. Monitors changes in
ascites formation and uid
accumulation.
5. Promotes patients
understanding of restriction
and cooperation with it.
6. Paracentesis will
temporarily decrease
amount of ascites present.

Ineffective breathing pattern related to ascites and restriction of thoracic excursion

secondary to ascites, abdominal distention, and uid in the thoracic cavity
GOAL: Improved respiratory status
Expected Outcomes
Experiences improved
respiratory status.
Reports decreased
shortness of breath.
Reports increased strength
and sense of well-being.
Exhibits normal
respiratory rate (1218/min)
with no adventitious
sounds.
Exhibits full thoracic
excursion with-out shallow
respirations.
Exhibits normal arterial
blood gases.
Exhibits adequate oxygen
saturation by pulse
oximetry.
Experiences absence of
confusion or cyanosis.

Nursing Interventions
1. Elevate head of bed to at
least 30 degrees.

2. Conserve patients
strength by providing rest
periods and assisting with
activities.
3. Change position every 2
h.
4. Assist with paracentesis
or thoracentesis.

a. Explain procedure and its

purpose to patient.
b. Have patient void before
paracentesis.
c. Support and maintain
position during procedure.
d. Record both the amount
and the character of uid
aspirated.
e. Observe for evidence of
coughing, increasing
dyspnea, or pulse rate.

Rationale
1. Reduces abdominal
pressure on the diaphragm
and permits fuller thoracic
excursion and lung
expansion.
2. Reduces metabolic and
oxygen requirements.
3. Promotes expansion and
oxygenation of all areas of
the lungs.
4. Paracentesis and
thoracentesis (performed to
remove uid from the
abdominal and thoracic
cavities, respectively) may
be frightening to
the patient.
a. Helps obtain patients
cooperation
with procedures.
b. Prevents inadvertent
bladder injury.
c. Prevents inadvertent
organ or tissue injury.
d. Provides record of uid
removed and indication of
severity of limitation of
lung expansion by uid.
e. Indicates irritation of the
pleural space and evidence
of pneumothorax or
hemothorax.

Chronic pain and discomfort related to enlarged tender liver and ascites
GOAL: Increased level of comfort
Expected Outcomes
Reports pain and
discomfort if present.
Maintains bed rest and
decreases activity in
presence of pain.
Takes antispasmodic and
analgesics as indicated and
as prescribed.
Reports decreased pain
and abdominal discomfort.
Reduces sodium and uid
intake to prescribed levels if
indicated to treat ascites.
Exhibits decreased
abdominal girth and
appropriate weight changes.
Reports decreased
discomfort after
paracentesis.

Nursing Interventions
1. Maintain bed rest when
patient experiences
abdominal discomfort.
2. Administer antispasmodic
and analgesic agents as
prescribed.
3. Observe, record, and
report presence and
character of pain and discomfort.
4. Reduce sodium and uid
intake if prescribed.
5. Prepare patient and assist
with paracentesis.
6. Encourage the use of
distracting activities such as
music, reading or
meditation.

Rationale
1. Reduces metabolic
demands and protects the
liver.
2. Reduces irritability of the
gastrointestinal tract and
decreases abdominal pain
and discomfort.
3. Provides baseline to
detect further
deterioration of status and to
evaluate interventions.
4. Minimizes further
formation of ascites.
5. Removal of ascites uid
may decrease abdominal
discomfort.
6. Distraction may limit the
perception of pain.

Risk for acute confusion

GOAL: Improved mental status; ability to cope with cognitive and behavioral changes
Expected Outcomes
Nursing Interventions
Rationale
Adheres to protein
1.Restrict protein, prescribe 1. Reduces source of
restriction.
for transient period
ammonia
Demonstrates an interest
2. Give frequent, small
2. Promotes consumption of
in events and activities in
feedings of carbohydrates.
adequate carbohydrates for
environment.
energy requirements and
Demonstrates normal
spares protein from
attention span.
breakdown for energy.
Follows and participates in 3. Protect from infection.
3. Minimizes risk for further
conversation appropriately.
increase in metabolic
Is oriented to person,place,
requirements.
and time.
4. Keep environment warm 4. Minimizes shivering,
Remains in bed when
and draft-free.
which would increase
indicated.
metabolic requirements.

 Reports no urinary or fecal

incontinence.
Experiences no seizures.
No neurological or
respiratory depression.
Develops no cognitive
impairments but if they
develop they are quickly
identied and treated
enhancing the potential of
recovery.
Patient and family
describe adequate
feelings of coping and
lowered anxiety. They
demonstrate ability to listen
and to make decisions as
able.
Patient and family
communicate their feelings
and their needs in a secure
and caring environment.

5. Pad the side rails of bed.

6. Limit visitors.
7. Provide careful nursing
surveillance to ensure
patients safety.
8. Avoid opioids and
barbiturates.

9. Awaken at intervals
(every 24 h) to assess
cognitive status.
10. Identify subtle changes
in behavior or sleepwake
pattern (consistent staff
caring for the patient
enhances this assessment as
they become familiar with
patients baseline).
11. Assess handwriting or
drawing skill as indication
of cognitive ability.
12. Encourage patient and
family to participate in
therapeutic strategies to
enhance coping with
episodes of mental
deterioration.
13. Encourage patient and
family to discuss feeling of
fear, powerlessness
or emotional distress related
to patients mental
deterioration.

5. Provides protection for

the patient should hepatic
coma and seizure activity
occur.
6. Minimizes patients
activity and metabolic
requirements.
7. Provides close
monitoring of new
symptoms and minimizes
trauma to the confused
patient.
8. Prevents masking of
symptoms of hepatic coma
and prevents drug overdose
secondary to reduced ability
of the damaged liver to
metabolize opioids and
barbiturates. Prevents
respiratory depression.
9. Provides stimulation to
the patient and opportunity
for observing the patients
level of consciousness.
10/11. These changes may
herald worsening of
encephalopathy which requires rapid intervention
including medication.

12. Promoting activities

such as listening
to music, relaxation
techniques or preillness
coping strategies can reduce
anxiety.
13. Actively listening
demonstrates caring and
concern.

Risk for imbalanced body temperature: hyperthermia related to inammatory

process of cirrhosis
GOAL: Maintenance of normal body temperature, free from infection
Expected Outcomes

Nursing Interventions

Exhibits normal
temperature and reports
absence of chills or
sweating.
Demonstrates adequate
intake of uids.
Exhibits no evidence of
local or systemic infection.
Develops no nosocomial
infections related to
invasive procedures/lines.

1. Record temperature
regularly (every 4 h).

Rationale

1. Provides baseline to
detect fever and to evaluate
interventions.
2. Encourage uid intake
2. Corrects uid loss from
perspiration and fever and
increases patients level of
.
comfort.
3. Apply cool sponges or ice 3. Promotes reduction of
bag for elevated
fever and increases patients
temperature.
comfort.
4. Administer antibiotics as 4. Ensures appropriate
prescribed.
serum concentration of
antibiotics to treat infection.
5. Avoid exposure to
5. Minimizes risk of further
infections.
infection and further
increases in body
temperature and metabolic
rate.
6. Keep patient at rest while 6. Reduces metabolic rate.
temperature is elevated.
7. Assess for abdominal
7. May occur with bacterial
pain, tenderness.
peritonitis.
8. Use sterile technique for
8. Many evidence-based
all invasive procedures.
practice guidelines (for
example central venous
catheter care) recommend
the use of sterile technique
to prevent nosocomial
infections.