The client with cirrhosis for your nursing review.
Lactulose is being given to a cirrhotic client (Cephulac). The nurse notices growing disorientation and asterixis during the examination. The nurse should do the following:
A. Check for gastrointestinal bleeding.
B. Keep the Lactulose in your hand (Cephulac).
C. Increase the amount of protein in your diet.
D. Keep an eye on your bilirubin levels in the blood.
The correct answer is A.Cirrhosis patients can develop hepatic encephalopathy as a result of elevated ammonia levels. Asterixis, or a flapping tremor, is a common sign of high ammonia levels. Bacterial action on excess protein in the intestine will raise ammonia levels, worsening the encephalopathy. GI bleeding and dietary protein increase protein in the intestine, which can raise ammonia levels. Lactulose is given to reduce ammonia production in the intestine and should not be delayed because neurological symptoms are getting worse. Jaundice is connected with bilirubin.
Results
#1. A cirrhotic client with hepatic encephalopathy is being assessed by a nurse. A decrease in which lab serum should be reported to the physician as a possible triggering factor for hepatic encephalopathy?
Hepatic encephalopathy is caused by hypokalemia, which is a precipitating factor. Muscle atrophy causes a drop in creatinine; an increase in creatinine indicates renal insufficiency. Increased aldosterone levels are reported with liver impairment. Reduced serum protein lowers colloid osmotic pressure, which promotes edema.
#2. A client has advanced liver cirrhosis. The client's spouse inquires about the reason for his enlarged abdomen, which makes it difficult for him to tighten his pants. What should the nurse say in order to give the most accurate description of the disease process?
Cirrhosis-related portal hypertension and hypoalbuminemia promote a fluid shift into the peritoneal cavity, resulting in ascites. Sodium can cause edema and decreased urine production in those who have a heart or kidney disease but not cirrhosis. Edema does not move upward toward the heart, which would improve circulation. Although diuretics aid in the outflow of excess fluid, forgetting or omitting a dose will not result in the ascites seen in liver cirrhosis.
#3. A nurse is putting together a treatment plan for a patient who has hepatic encephalopathy. Which of the following are the aims for this client's care? All that apply should be selected.
Ammonia generation rises as a result of constipation. Lactulose (Cephulac) is a hyperosmotic laxative that lowers blood ammonia levels by acidifying colon contents, which slows nonionic ammonia diffusion from the colon to the blood while speeding up its migration from the blood to the colon. Hepatic encephalopathy is a toxic or metabolic illness that generates cerebral edema and has an impact on a person’s coordination, pupil response to light, and accommodation. Because the liver is unable to synthesize and store glucose, high-carbohydrate foods and beverages should be supplied. Physical activity should be controlled, not encouraged, because it produces ammonia as a byproduct of metabolism.
#4. The nurse is evaluating a patient who is in the early stages of liver cirrhosis. Which type of targeted assessment is best?
Cirrhosis has a number of early clinical signs, the most common of which are gastrointestinal symptoms such as anorexia, nausea, vomiting, and abnormalities in bowel habits. The liver’s ability to digest carbohydrates, proteins, and fats has been altered, resulting in these modifications. Later symptoms of liver failure and portal hypertension include peripheral edema, ascites, and jaundice.
#5. A client with cirrhosis develops ascites at the age of 49. The drug spironolactone (Aldactone) is used to treat ascites. Which of the following drug-related side effects should the nurse keep a close eye on?
Because spironolactone (Aldactone) is a potassium-sparing diuretic, patients should be regularly monitored for hyperkalemia. Abdominal cramping, diarrhea, dizziness, headache, and rash are all frequent side effects. Constipation and dysuria are not common spironolactone side effects. Spironolactone does not cause an irregular pulse, but it could develop if serum potassium levels are not regularly controlled.
#6. What diet should a cirrhotic client follow in the early stages of the disease?
A high-calorie, high-carbohydrate diet is preferred to give an appropriate supply of nutrients for individuals with cirrhosis who do not have problems. There is no need to restrict fat, protein, or sodium in the early stages of cirrhosis.
#7. A client with jaundice has pruritus and claims that scratching has irritated his skin. What options does the nurse have for preventing skin breakdown? All that apply should be selected.
Pruritus can be relieved by bathing with baking soda. When scratching is unavoidable, such as during sleep, keeping nails short and rubbing with knuckles might help to prevent breakdown. Calamine creams are used to treat the itching. Alcohol causes the skin to become drier. Edema and skin integrity are both weakened by sodium in the diet.
#8. Which of the following health promotion activities would the nurse recommend that the cirrhotic client incorporate into his or her regular routine at home?
Maintaining adequate nutrition, preventing infection, and abstaining from alcohol are all general health promotion practices. Rest and sleep are important, but sedatives and barbiturates may be difficult to detoxify if your liver is damaged. Clients with cirrhosis should use such medications with caution, if at all. The client does not need to limit his or her contact with others, but he or she should exercise caution around sick people.
#9. The nurse is going over the patient's chart for a client who has developed ascites. Temperature 37.2°C; heart rate 118; shallow respirations 26; blood pressure 128/76; and SpO2 89 percent on room air are among the statistics. Which of the nurse's actions should be prioritized?
By reducing the amount of ascites resting on the diaphragm, elevating the head of the bed allows for more lung expansion. A reassessment of the client is required. A paracentesis is reserved for symptomatic patients with ascites, decreased breathing, or abdominal pain who have failed to react to previous treatments such as salt restriction and diuretics. There is no reason to take blood cultures. The heart sounds are evaluated as part of the normal physical examination.
#10. For a client with severe ascites, which of the following positions would be appropriate?
Ascites can impair the diaphragm’s function, putting the client at danger for respiratory difficulties. Skin degradation is also considerably increased by ascites. Posture adjustments are important, although Fowler’s is the preferable position. By releasing pressure on the diaphragm, placing the client in Fowler’s position aids the client’s breathing. The other postures do not reduce diaphragm pressure.
