A nurse is caring for a client who has been admitted to the hospital.
Nurses’ Notes.
0900:
The client reports experiencing a loss of appetite and shortness of breath within the last month or so. The client reports experiencing weakness, abdominal pain, severe itching, and mood changes. The client has had alcohol use disorder for the past 10 years and sometimes drinks alcohol uncontrollably.
The client is alert but disoriented to time. Their abdomen is bloated and they have redness of the palms of the hands. Excoriated areas on the upper thorax and shoulders are present. Sclera are yellow.
1230:
Administered antacids, spironolactone, and colchicine per provider’s prescription.
Vital Signs.
0930:
Temperature 37.3° C (99.1 F).
Heart rate 84/min.
Respiratory rate 20/min.
BP 138/88 mm Hg.
Oxygen saturation 93% on room air.
1600:.
Temperature 37° C (98.6° F).
Heart rate 80/min.
Respiratory rate 20/min.
BP 130/85 mm Hg.
Oxygen saturation 94% on room air.
Laboratory Results.
1200:
Hgb 9.5 g/dL (14 to 18 g/dL).
Het 38% (42% to 52%).
Bilirubin 5.3 mg/dL (0.3 to 1.0 mg/dL).
Creatinine 1.8 mg/dL (0.6 to 1.3 mg/dL).
Platelet count 100,000/mm (150,000 to 400,000/mm).
1800:
Alanine aminotransferase ALT 51 units/L (4 to 36 units/L) Aspartate aminotransferase AST 48 units/L (0 to 35 units/L) Alkaline phosphate ALP 151 units/L (30 to 120 units/L) Blood total protein 15 g/dL (6.4 to 8.3 g/dL).
Select the 5 actions the nurse should take.
A.
Provide frequent rest periods for the client.
B.
Instruct the client to avoid blowing their nose forcefully.
C.
Assess the client s level of orientation.
D.
Place the client on a low-carbohydrate diet.
E.
Restrict the client’s sodium intake.
F.
Advise the client to avoid the use of soap and alcohol-based lotions.
G.
Place the client under contact isolation.
The Correct answer and Explanation is:
The correct actions the nurse should take in caring for this client are:
A. Provide frequent rest periods for the client.
C. Assess the client’s level of orientation.
E. Restrict the client’s sodium intake.
F. Advise the client to avoid the use of soap and alcohol-based lotions.
B. Instruct the client to avoid blowing their nose forcefully.
Explanation:
The client in this scenario presents with multiple symptoms, most of which are related to chronic liver disease, likely cirrhosis, as suggested by their history of alcohol use disorder and physical findings such as jaundice, palmar erythema, and ascites (bloated abdomen). Additionally, lab values indicate liver dysfunction, including elevated bilirubin, ALT, AST, ALP, and reduced hemoglobin and platelets.
- Provide frequent rest periods for the client (A):
Liver dysfunction often leads to fatigue and weakness. In this case, the client has reported weakness, which is a common symptom of cirrhosis. Providing frequent rest periods will help conserve the client’s energy and improve their ability to engage in activities of daily living. - Assess the client’s level of orientation (C):
The client is alert but disoriented to time, suggesting possible hepatic encephalopathy, a condition caused by the accumulation of toxins like ammonia in the brain due to poor liver function. Regular assessments of orientation are crucial to monitor for worsening cognitive impairment or confusion. - Restrict the client’s sodium intake (E):
The client’s bloated abdomen likely indicates ascites, which is the accumulation of fluid in the peritoneal cavity, commonly associated with cirrhosis. Sodium restriction helps manage fluid retention and prevent worsening ascites, as excess sodium promotes water retention. - Advise the client to avoid the use of soap and alcohol-based lotions (F):
The client has severe itching and excoriations on their thorax and shoulders, likely due to pruritus, a common symptom in liver disease caused by high levels of bile salts in the skin. Soaps and alcohol-based lotions can further irritate the skin, exacerbating the itching. Gentle cleansers and moisturizers should be recommended instead. - Instruct the client to avoid blowing their nose forcefully (B):
The client’s platelet count is low (100,000/mm³), indicating thrombocytopenia, a common complication of liver disease. Thrombocytopenia increases the risk of bleeding, and forcefully blowing the nose could lead to epistaxis (nosebleeds). Therefore, the nurse should instruct the client to avoid actions that could cause bleeding, including nose blowing or vigorous coughing.
Incorrect options:
- Low-carbohydrate diet (D):
There is no indication that a low-carbohydrate diet is necessary in this scenario. Clients with liver disease typically benefit from a balanced diet that includes adequate protein to prevent muscle wasting. - Contact isolation (G):
The client does not have an infection or condition that would require contact isolation. Liver disease, in this case, does not pose a risk of infection to others.
These nursing actions will help address the client’s current symptoms and prevent further complications associated with liver disease.