Assessment of a client with cirrhosis reveals a distended abdomen, weight gain, and dyspnea. Based on this information, what interventions would the nurse include in this client’s plan of care?
A.
Implement a sodium restriction.
B.
Encourage fluids.
C.
Check lipase level.
D.
Administer pancrealipase.
The Correct Answer and Explanation is:
The correct answer is A. Implement a sodium restriction.
Explanation:
In a client with cirrhosis, the symptoms of a distended abdomen, weight gain, and dyspnea are indicative of fluid retention and possible ascites. Ascites, the accumulation of fluid in the abdominal cavity, is a common complication of cirrhosis and is often associated with hepatic portal hypertension and decreased albumin production. Managing ascites effectively involves addressing the fluid overload, which can help alleviate symptoms such as abdominal distension and dyspnea (shortness of breath).
A. Implement a sodium restriction: Sodium restriction is a key intervention in managing ascites associated with cirrhosis. Sodium is known to cause fluid retention because it binds with water in the body. Reducing sodium intake helps to decrease fluid retention and, consequently, reduces abdominal distension and weight gain. This dietary modification helps prevent the exacerbation of ascites and can improve overall comfort and breathing.
B. Encourage fluids: Encouraging fluid intake is contraindicated in this situation. The client is already experiencing fluid overload, as evidenced by the distended abdomen and weight gain. Increasing fluid intake could worsen the ascites and lead to further complications, including more severe dyspnea and abdominal discomfort.
C. Check lipase level: Lipase is an enzyme related to pancreatic function, particularly in the digestion of fats. While elevated lipase levels can indicate pancreatic issues, they are not directly related to the symptoms described in this case, such as ascites or fluid retention. Checking lipase levels would not address the primary concern of fluid management in cirrhosis.
D. Administer pancrealipase: Pancrealipase is used to aid digestion in individuals with pancreatic insufficiency. This medication is not relevant to the management of ascites or fluid retention related to cirrhosis. It would not address the fluid overload and associated symptoms like abdominal distension and dyspnea.
In summary, implementing a sodium restriction is a critical intervention for managing ascites and fluid retention in clients with cirrhosis. It helps to control fluid buildup, reduce discomfort, and improve overall respiratory function.