Cirrhosis HESI Case Study (evolve)

Case OutcomeThe social worker is able to meet with the client. The social worker arranges a meeting with a substance abuse counselor and the client says that they will attend Alcoholics Anonymous meetings with a sponsor. The client is discharged from the hospital in stable condition with plans to stop drinking and to maintain a healthy lifestyle. During the client's discharge education, which complication of cirrhosis should the nurse instruct the client to report immediately? Two pound weight gain in one week. Progressive evidence of cachexia. Prolonged icteric sclera. Hemoptysis after taking ibuprofen for a headache.

Hemoptysis after taking ibuprofen for a headache. Hemoptysis is coughing up blood. This may be evidence of a life threatening esophageal bleed.

The nurse continues the focused risk assessment by asking about etiologic factors related to cirrhosis. Which assessment finding provides the most likely indication that the client is at high risk for cirrhosis? Previous diagnosis of Hepatitis C. Steady diet of high protein foods. Exposure to toxic substances at work. Familial evidence of cirrhosis.

Previous diagnosis of Hepatitis C. Hepatitis C is directly linked to cirrhosis, as well as Hepatitis B and D.

Management Issues: Interprofessional Team CollaborationThe client states that they want to stop drinking and get their life under control. The client is agreeable to change their lifestyle so they can return to productive employment. The client asks the nurse how to begin the process. Which member of the inter-professional team is the best choice for the nurse to contact to help the client meet this goal? Hospital chaplain The charge nurse Dietician Social worker

Social worker The social worker has expertise in coordinating community resources and social services and is, therefore, the best member of the interprofessional team to help the client with their lifestyle goals.

While administering the albumin infusion via a vein in the right hand, the nurse notes that the peripheral edema in the client's arms and hands has changed from 3+ to 2+. It is most important for the nurse to implement which intervention? Administer a diuretic. Change the IV site. Stop and check the client's blood pressure. Continue the albumin infusion.

Continue the albumin infusion. This finding reflects a decrease in edema. Since this indicates the albumin is having the desired effect, it should be continued. Albumin is administered to pull fluid from the peritoneal cavity and peripheral tissues. Excessive use of albumin without adequate diuresis may result in pulmonary edema, which is manifested by symptoms such as abnormal breath sounds and jugular vein distention.

Hepatic EncephalopathyTwo days later, the client is transported back to the emergency department by ambulance. The nurse assesses the client's responses using the Glasgow Coma Scale (GCS). The nurse's focused assessment findings include: Eyes open in response to pain. Only mumbles when asked a question. Arm flexes in response to pain. What is client's Glasgow Coma Scale rating obtained in this assessment? (Enter numerical value only. If rounding is necessary, round to the nearest whole number.)

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The nurse discusses the situation with another nurse who states that the client should have been sedated and restrained to keep them from leaving. In which situations is the use of physical restraints appropriate? (Select all that apply. One, some, or all options may be correct.) Select all that apply A combative and agitated client who is pulling at the indwelling catheters and IV lines. A client who verbally abuses the staff. A client who is at high risk for injury to self for whom no other safety measures have been successful. A client who is at high risk for injury because of insufficient nursing personnel. A disoriented client who is trying to dislodge a tracheotomy tube.

A combative and agitated client who is pulling at the indwelling catheters and IV lines. This would be appropriate to prevent harm to the client. A client who is at high risk for injury to self for whom no other safety measures have been successful. The nurse must be able to document not only the clear need for the use of restraints, but also the other avenues of protection that have been attempted prior to the use of restraints. A disoriented client who is trying to dislodge a tracheotomy tube. This information is an indication that the client is a danger to self, which indicates the need for restraints.

Therapeutic Communication: DenialWhen the nurse enters the client's room, they express how they are tired of everybody calling them an alcoholic. The client expresses that they don't really drink that much, and can cut back at anytime. The client states that they do not drink more than any other average guy and feels that people are just labeling them for no reason which makes them angry. What is the best approach for the nurse to use when responding to the client? Assure the client that the hospital staff understand. Ask the client why he feels people are judging them. Find out if the client has alcoholic friends. Tell the client they have a right to be upset.

Ask the client why he feels people are judging them. Two primary characteristics of the alcoholic are denial and rationalization. The client using denial as a defense mechanism should not be forced to face an issue with which he is not able to cope. However, the treatment of the alcoholic requires a style of more direct, but not confrontational or antagonizing, communication than that of a client utilizing denial related to a grief process.

The nurse contacts the social worker who states they are too busy and unable to meet with the client. What is the best response by the nurse? Tell the client that the social worker will visit another time. Emphasize the concern for the client's wellbeing and need for a social worker. Demand to speak to the social worker's supervisor. Have another nurse provide the resources that the social worker would have given.

Emphasize the concern for the client's wellbeing and need for a social worker. Collaboration requires assertive, not aggressive, communication skills, and respect for the members of other disciplines. This response also demonstrates client advocacy.

The client asks the nurse what makes everyone think that they are an alcoholic. The client states when they drink, they don't have to think about problems and that others must feel the same way. How should the nurse respond to the client? Explain that their lab values are consistent with alcohol abuse. Ask the client if they are worried about becoming an alcoholic. Providing the client with a screening tool for alcoholism. Refer to the client's blood alcohol level at admission.

Explain that their lab values are consistent with alcohol abuse. Liver enzymes are not elevated until serious damage has occurred after years (10+) of drinking alcohol. Additionally, alcoholism includes at least two social complications due to excessive use of alcohol. The nurse is aware of the client's accident and blood alcohol level that precipitated hospitalization.

With a confirmed diagnosis of Laennec's cirrhosis, which assessment finding warrants immediate intervention? (Select all that apply. One, some, or all options may be correct.) Select all that apply Increased girth Scleral jaundice Hematemesis Melena Pruritus

Hematemesis Bloody emesis (hematemesis) is a sign of active bleeding, possibly rupture of esophageal varices and requires immediate intervention. Melena Dark, tarry stool (melena) is a sign of active bleeding and requires immediate intervention.

The HCP orders the following: Lactulose 300 mL retention enema every 6 hours Rifaximin 550 mg BID via nasogastric tube 5% Dextrose Injection IV Which outcome indicates to the nurse that the lactulose and rifaximin are having the desired effect? Increased mental alertness. Decreased craving for alcohol. Decreased serum albumin level. Clay-colored bowel movements.

Increased mental alertness. One of the primary goals of treatment is to improve the client's neurologic status. The prescribed medications are administered to increase the frequency of bowel movements, which increases the excretion of ammonia in the bowel, thereby reducing the elevated serum ammonia level that is causing the toxic effects on the CNS.

Clinical ManifestationsThe client has several lab values which indicate Laennec's cirrhosis, a liver disease. The client has an increase in total serum bilirubin and serum alkaline phosphatase levels, a prolonged APTT, and elevated liver enzymes. The client states that they become increasingly fatigued, and even though appetite is poor, abdomen is becoming enlarged. Client also reports that they bruise easily and they get frequent nosebleeds. Based on the prolonged APTT and PT/INR what clinical manifestation would the nurse anticipate visualizing upon assessment? Weight loss Peripheral edema Jaundice Petechiae

Petechiae The client with cirrhosis has impaired coagulation related to a decrease in the production of clotting factors by the liver, decreased absorption of vitamin K in the intestines, and thrombocytopenia. Manifestations may include epistaxis, purpura, and petechiae.

The client is minimally responsive and has a Glasgow Coma Scale rating of 8. The client is admitted with a diagnosis of hepatic encephalopathy. Which of the client's serum laboratory values requires intervention by the nurse? Serum ammonia 157 mcg/dL (112.1 mcmol/L) pH 7.50 PaCO2 50 mmHg Serum albumin 0.60 g/dL (6 g/L)

Serum ammonia 157 mcg/dL (112.1 mcmol/L) Increased ammonia levels are toxic to CNS tissue, resulting in encephalopathy. Serum ammonia levels increase in cirrhosis as the liver becomes less efficient in converting ammonia to urea. The client is disoriented to time, loss of meaningful conversation, marked confusion, incomprehensible speech. Serum ammonia normal range 10.0-80.0 mcg/dL (7.14-57.12 mcmol/L).

Medical ManagementThe healthcare provider (HCP) orders the following: Spironolactone 75 mg PO daily Furosemide 20 mg PO BID 20% albumin 75 g IV daily via saline lock Vitamin K 10 mg IM now Folic acid 1 mg PO daily Thiamine 100 mg IM now Thiamine 50 mg PO daily × 5 days Which medication places the client at risk for hyperkalemia? Spironolactone. Furosemide. Folic acid. Thiamine.

Spironolactone. This potassium-sparing diuretic prevents potassium from being excreted, so the client should be monitored for signs of hyperkalemia.

In the client with cirrhosis, which lab values does the nurse anticipate will be increased from the normal value? (Select all that apply. One, some, or all options may be correct.) Select all that apply Total serum bilirubin AST/ALT Serum albumin APTT, PT/INR Sodium and potassium

Total serum bilirubin The diseased liver is not able to metabolize bilirubin efficiently, resulting in an increase in total serum bilirubin. AST/ALT AST/ALT will be increased, reflecting the diseased liver function. APTT, PT/INR Tests that reflect clotting time will be prolonged, or increased, because the diseased liver produces less clotting factors. Also, the intestine absorbs less vitamin K because the liver is producing less of the bile that is necessary for vitamin K absorption.

Nursing care for the client focuses on conserving strength while maintaining muscle strength and tone. Which interventions should the RN/PN include in the client's plan of care? (Select all that apply. One, some, or all options may be correct.) Select all that apply Assess pressure areas while turning every 2 hours. Space nursing care to provide uninterrupted periods of rest. Administer PRN antiemetics before meals. Encourage the client to eat frequent high-protein snacks. Increase activity as tolerated.

Assess pressure areas while turning every 2 hours. Clients may require complete bed rest or have decrease in activity tolerance. The nurse should implement measures to prevent pneumonia, thromboembolic problems, and pressure ulcers. Space nursing care to provide uninterrupted periods of rest. Activity should be modified and rest schedule according to signs of clinical improvement (e.g., decreasing jaundice, improvement in liver function studies). Increase activity as tolerated. Activity should be modified and rest schedule according to signs of clinical improvement (e.g., decreasing jaundice, improvement in liver function studies).

Client Teaching: Lifestyle ManagementThe client is experiencing bleeding esophageal varices. They are given a liter bolus of sodium chloride 0.9% IV and they are scheduled for immediate endoscopic sclerotherapy. Following endoscopic sclerotherapy, the client's bleeding stops and condition stabilizes. The client tells the nurse that they think it's time to learn about their condition. The client expressed fear of dying. The nurse provides the client with the information about managing diet and fluid intake. Dietary management includes a well-balanced diet that is low in sodium, fat, and physical irritants with a mild fluid restriction. The nurse provides additional discharge teaching regarding lifestyle management. Which information should the nurse provide to the client? (Select all that apply. One, some, or all options may be correct.) Select all that apply Reduce alcohol intake to one drink daily. Get plenty of rest and regular exercise. Avoid the consumption of raw shellfish. Take a vitamin supplement weekly. Consider joining an Alcoholic Anonymous (AA) group.

Get plenty of rest and regular exercise. This is important to maintain the client's health. Avoid the consumption of raw shellfish. This is a priority because of the existing damage to the liver. Raw shellfish has a risk of causing hepatitis. Consider joining an Alcoholic Anonymous (AA) group. The client may need referral to AA, psychiatric counseling, or spiritual counseling as he attempts to detox from alcohol.

After the client undergoes the paracentesis, which nursing assessment warrants immediate intervention? Cloudy, yellow tinged fluid draining from puncture site Unchanged abdominal girth measurement Faint, hypoactive bowel sounds Increasing abdominal pain

Increasing abdominal pain This may be the result of diaphragmatic, liver, or spleen perforation and may be life threatening.

Ethical-Legal Considerations: Discharge Against Medical Advice (AMA)The client becomes increasingly angry and leaves the hospital without discharge orders from the HCP. Who should the nurse notify of the client's action? (Select all that apply. One, some, or all options may be correct.) Select all that apply The client's next of kin. The charge nurse. The police. The client's HCP. The local Alcoholics Anonymous group.

The charge nurse. The charge nurse should be notified of all unexpected actions on the unit, including a client leaving AMA. The client's HCP. The client's HCP should be notified of the following: that the client has left, the relevant circumstances, and the client's condition at the time of departure.

The nurse positions the client in bed, calls for assistance, and assesses the client's vital signs and oxygen saturation level. Vital signs are: temperature 98.6° F (37° C), heart rate 148 beats/min, respirations 32 breaths/min, and blood pressure 70/36 mmHg and oxygen saturation level is 82%. In what order should the nurse perform the following actions? (Place in numerical order from first action through last action.) Transfer to critical care Notify the RRT Ensure patency of the IV Apply Oxygen mask

Apply Oxygen Ensure patency of IV Notify Rapid Response Team (RRT) Transfer to critical care Since the client's oxygen saturation level is 86%, the nurse should apply oxygen via nasal cannula or face mask to improve oxygenation. The client is displaying symptoms of shock and requires immediate intervention. The client is experiencing bleeding esophageal varices and impending shock. The client will require IV fluids and possibly a blood transfusion or IV vasopressors to maintain blood pressure. The client's vital signs indicate a medical emergency requiring immediate intervention. The rapid response team should be notified of the overt bleeding and impending shock, but two other actions should be taken first. The rapid response team can treat and move the client to the critical care unit after the nurse provides oxygen and ensures IV access.

A Complication OccursThe client's condition remains stable. The client is getting plenty of rest, alternating with periods of exercise. The client is having difficulty following the prescribed diet however, occasionally friends will bring in chips and soft drinks. Late one afternoon, the client calls for the nurse and reports that they feel dizzy and that they are vomiting bright red blood. When the nurse arrives, the client is standing in the middle of the room. The client is pale and skin feels cold and clammy. What intervention is a priority for the nurse? Take and record the client's blood pressure. Go to the med cart to obtain an antiemetic. Call for the laboratory to draw a STAT CBC. Assist the client to bed and position them side lying. Submit

Assist the client to bed and position them side lying. The client is showing evidence of impending shock. Because they are vomiting, the safest position for the client would be side lying to prevent aspiration.

Diagnostic TestsSeveral tests are ordered to confirm the diagnosis of cirrhosis and to assess the degree of liver damage and related complications. The client is scheduled for a liver biopsy, paracentesis, and hepatic angiography. Which nursing interventions are important prior to a paracentesis? (Select all that apply. One, some, or all options may be correct.) Select all that apply Ensure the client has signed a consent. Instruct the client to empty their bladder. Position the client in an upright position. Administer medication for conscious sedation. Apply sphygmomanometer to monitor blood pressure.

Ensure the client has signed a consent. This is an invasive procedure. The client should have instructions about the procedure and sign a consent form. Instruct the client to empty their bladder. Paracentesis involves the removal of peritoneal fluid for evaluation, and it is also performed to drain excess peritoneal fluid. Prior to the procedure, the client should be instructed to void to reduce the risk for accidental rupture of the bladder during the procedure. After the procedure, the client should be assessed for signs of peritonitis or peritoneal bleeding. Position the client in an upright position. This positioning is used for a paracentesis. If the client is in the bed, a Fowler's position can be used. Apply sphygmomanometer to monitor blood pressure. The client's blood pressure should be monitored during the procedure.

Meet the Client A client is brought to the Emergency Department following an automobile accident. The car the client was driving swerved off the road into the median, where the car's front end hit a highway bridge. The client is treated for minor injuries, and several lab tests are ordered. The client's blood alcohol level (ethyl alcohol) is 20 mg/dL (4.34 mmol/L), and liver enzymes are elevated. Assessment findings include lethargy, an enlarged liver on palpation, jaundiced skin and sclera, and ascites. The client is admitted for further evaluation with a medical diagnosis of cirrhosis. The following morning when the client is more alert and the nurse is able to obtain a more thorough history. Etiologic FactorsDuring the focused nursing assessment, the client's spouse ask the nurse if it is true that only alcoholics get cirrhosis. Which nursing intervention best promotes accurate and effective communication? List the reasons only alcoholics get cirrhosis. Explain that there are several types of cirrhosis. Illustrate how all alcoholics will eventually develop cirrhosis. Define the difference between social drinkers and alcoholics.

Explain that there are several types of cirrhosis. There are several types of cirrhosis with differing etiologies. Cirrhosis can have a variety of etiologies including viral hepatitis, non-alcoholic fatty liver disease, hemochromatosis, Wilson's disease, cystic fibrosis, biliary atresia, infections, and medications.

Management of ascites is focused on sodium restriction diet, diuretic therapy, and fluid removal. While monitoring the client's fluid volume, what action should the nurse take? Instruct the client to perform self-catheterization. Measure abdominal girth daily. Administer PRN antiemetics before meals. Encourage the client to eat frequent high-protein snacks.

Measure abdominal girth daily. Assessment of the effectiveness of treatment for fluid volume excess includes measuring abdominal girth and edema, auscultation of breath sounds, and daily weights. Ascites frequently returns after paracentesis. Another important intervention is to maintain fluid and sodium restrictions. Fluids may be restricted to 1 liter or less a day, and sodium may be restricted to 1 g or less a day.

Nursing Diagnoses and InterventionsTreatment of the client's encephalopathy is successful. The client is started on a regimen of care for cirrhosis. The RN and PN identify several high-priority nursing problems, including: Activity intolerance Disturbed body image Imbalanced nutrition (less than body requirements) Impaired skin integrity Fluid volume excess The treatment goal for cirrhosis is to slow the progression, prevent and treat any complications. Which interventions are most important for the nurses to include in the client's plan of care? (Select all that apply. One, some, or all options may be correct.) Select all that apply Stress the importance of following a low sodium diet. Empasize the need for B-complex vitamins. Encourage low-carbohydrate foods. Teach the client to change positions frequently. Use moisturizing lotion to the skin to minimize scratching.

Stress the importance of following a low sodium diet. Ascites and edema will worsen if diet is high in sodium Empasize the need for B-complex vitamins. Clients should receive a high protein diet, with supplemental B complex vitamins as well as A, C, and K. Folic acid and iron are used to prevent anemia. Use moisturizing lotion to the skin to minimize scratching. Lotion may be soothing to irritated skin. Irritating soaps and the use of adhesive tape are avoided to prevent trauma to the skin.