Lesson 61. Nursing Implications For the Patient With Cirrhosis
1-61. NURSING IMPLICATIONS FOR THE PATIENT WITH CIRRHOSIS a. Assess for Fluid Retention. - (1) Weigh daily.
- (2) Measure abdominal girth daily.
- (3) Observe and record accurate intake and output.
- (4) Observe for the presence of edema.
b. Observe for Bleeding Tendencies. - (1) Monitor vital signs frequently.
- (2) Assess for anxiety, weakness, or abdominal fullness that may indicate internal bleeding.
- (3) Observe and test stool, urine, and emesis for the presence of blood.
- (4) Observe the gums for evidence of bleeding.
- (5) Observe the skin for petechiae and bruising.
c. Manage Bleeding Tendencies. - (1) Provide a safe environment to prevent injuries.
- (2) Implement the use of a soft bristle toothbrush.
- (3) Implement the use of an electric razor for shaving instead of a blade razor.
- (4) Use small gauge needles for drawing blood and starting IVs.
- (5) Caution the patient against forceful nose blowing to prevent epistaxis.
d. Provide Skin Care. - (1) Use gentle cleansers to decrease skin irritation.
- (2) Use soothing lotions to control the itching that occurs as a result of bile salt retention.
- (3) Administer prescribed medications for pruritis.
- (4) Keep the patient's fingernails short to prevent scratching the skin.
e. Observe and Assess for Indications of Hepatic Encephalopathy. - (1) Arouse the patient at intervals and assess level of consciousness and orientation to place and time.
- (2) Observe for personality changes or mental changes.
- (3) Observe for signs of increasing lethargy.
- (4) Observe for signs of neuromuscular dysfunction.
- (5) Observe for evidence of hallucinations.
f. Provide Emotional Support. - (1) The patient will experience fatigue and malaise as a normal consequence of the illness. Assure him that this is normal and will eventually resolve.
- (2) Educate the patient and his family about the nature of the illness so that they will be better able to cope.
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