University:
American Career College
Course:
NURS112 | Fundamentals of Nursing
Academic year:

2021
Views:

288

Pages:

1
Author:

Alexa Livingston

Nursing Diagnosis #1: Acute Confusion AEB decreased cognition and memory problems r/t neurosensory changes occurring with cerebral accumulation of ammonia (210). Nursing Interventions w/rationale: 1. 2. Have patient demonstrate signature, if writing deteriorates hepatic encephalopathy may be worsening Be alert to generalized muscle twitching and asterixis then report to health care provider, asterixis may be present in advanced encephalopathy Goals: (Short & Long term) ST: pt exhibits intact signature compared to baseline signature twice every 8 hours. LT: pt exhibits no signs of neurosensory changes like slowed speech or memory impairment by discharge. Nursing Diagnosis #2: Decreased Gas Exchange AEB by shallow breathing with RR of 18 r/t ascites. Nursing Interventions w/rationale: 1. Monitor SpO2 for <92% and administer oxygen as prescribed, lower than 92% oxygen can cause hypoperfusion 2. Teach use of incentive spirometry, using the incentive spirometer helps with the expansion on alveoli and aids in mobilizing secretions to the airway Nursing Diagnosis #3: Risk for impaired skin integrity AEB immobility r/t weakness and loss of balance. Nursing Interventions w/rationale: Goals: (Short & Long term) ST: pt uses incentive spirometer once every 2 hours. LT: pt verbalizes three ways to maintain SpO2 > 92% by discharge. Evaluation: ST (met), LT (on going) Subjective: memory problems, weakness, mood/personality changes, loss of balance Objective: decreased cognition, irritability, hypertonia, hyper-reflexia, dyskinesia, slowed speech, oral temp 99.2F, 79 HR, 18 RR, 92/52 BP, SpO2 100% on 40% facemask Diagnostics: BUN 29 (10-26) Creatinine 5.88 (0.5-1.24) Hct and Hgb for anemia Hyponatremia and hypokalemia Ammonia 210 (<35) WBC No definitive test but may use EEG, MRI, CT to rule out other diagnoses Medical Hx, symptoms, physical exam Inspect pressure points and skin surfaces because edematous tissues are more prone to skin breakdown 2. Provide perineal care following urination and bowel movement to prevent skin breakdown from urine and stool Goals: (Short & Long term) ST: pt rotates body positions with assistance at least 6 times by end of shift. LT: pt verbalizes three ways to prevent skin breakdown by discharge. Evaluation: ST (met), LT (on going) Assessment: 63 white male, 23.8 BMI 1. Disorder: Acute Hepatic Encephalopathy Evaluation: ST (met), LT (on going) . Medications: Lactulose Antibiotics: Metronidazole, Xifaxan, Pathophysiology: Impaired liver metabolism and portal hypertension causes a buildup of ammonia in the systemic circulation. This build up allows ammonia to cross the blood brain barrier where it is converted into glutamine. Glutamine causes swelling in the astrocytes which produce reactive oxygen species. The combination of NH₃, glutamine, and ROS in the brain causes edema and altered mental status. Risk Factors: HTN, DM, chronic liver disease, cirrhosis, alcohol use, dialysis, MI, aging, ascites, Hepatitis B & C, infection, constipation, high protein diet, GI bleeds Vancomycin, neomycin Complications & Actions to Prevent: Altered mental status Asterixis Myoclonus Hepatic coma Jaundice Gallstones Splenomegaly Esophageal varices Edema and ascites