Need help with nursing care plan for ESLD

[scotland19]

I have came to a mental road block! I am in my first semester of nursing school and working on my care plan. My patient is in ESLD, ascites, recent shunt placement, malnutrition, narcotic dependence, depression, unsteady gait, visual impairment, poor safety judgment, poor gait, bruising to the extremites and chest. I have 2 nursing dx so far, I'm having a hard time coming up with the third dx. Here is what I have so far

Nursing Diagnosis: Excess fluid volume R/T recurrent ascites

Goal/Outcome: Pt will have ↓ extracellular fluid volume by weight loss, decreased peripheral edema, clear lung sounds, and normal heart sounds for the next 60 days.

Actions:

1. Monitor I & O every 24 hrs and chart weight gain more then 0.5 kg/day

2. Monitor abdominal girth

3. Consult dietitian regarding low sodium diet and fluid restriction.

Rationales:

1. Reflect circulating volume status. Positive balance/weight gain often reflect continuing fluid retention

2. Reflects accumulation of fluid (ascites) resulting from loss of plasma proteins or fluid into peritoneal space.

3. ↓ renal flow results in increases of aldosterone and antidiuretic hormone secretion, water and sodium retention as well as potassium excretion which contributes to edema formation.

Nursing Diagnosis: Risk for impaired skin or tissue integrity R/T incisions, bruising and itching

Goal/Outcome: Incision site will show no signs of infection & skin will remain intact for at least 60 days

Actions:

1. Assess entire skin surface noting color, turgor, temperature and sensation.

2. Clean incision site as indicated by physicians order to facilitate healing and prevent infection. Using aseptic technique.

3. Clean every 8 hours on areas of itching and assess healing.

Rationales:

1. Regular skin inspection enables early detection of damage and infection. Infected wounds will require more of both medical and nursing interventions.

2. Aseptic technique reduces the entry of pathogens into the wounds

3. ↓ chance of infection.

Any help our suggestion is greatly appreciated.

Thank you.

[enchantmentdis, BSN, RN]

You need pt/ptt/inr; any esophageal varices?, portal hypertension?--most likely. Be sure to allow much less than 4 gm acetominophen daily. limit meds that cause bleeding-overt or covert. Do a care plan relating to the bleeding possibility, and possibilityof liver/blood toxicity due to various meds,--any meds that adversly affect the blood levels and liver MUST be sparingly used. DO NOT forget hepatic encephalopathy possibility in your care planning. Is there also kidney damage?--if so diuretics might not help much and will cause acute renal failure in most chronic diabetic IIs. Some docs will order high doses of diuretics knowing the pt will go into renal failure that will compensate itself and improve renally eventually--this is standard, but will not improve if pt has multi-organ failure; then pt belongs in the icu and code status should be in place. Intubation is highly likely at some point. Grim diagnosis w/ palliation or hospice a helpful option in the home or snf but not the hospital unless intractable pain and pt can have a drip. Has pt had a paracentesis or thoracentesis and how much fluid removed and what was the quality/consistency of it? Is there a dressing? Don't forget bowel care, and of course possibility of septic shock, any infection, hypovolemic shock, dvts. and does patient have a cvp, central line? And edema and ascites predisposes the patient to skin impairments. Is ascites w/ burgeoning abdominal girth affecting the pts breathing/.Has the pt had an ercp, cholecystectomy, is there any scarring on the abdomen?--possibility of adhesions and subsequent bowel obstructions. Urinary retention often occurs w/immobility--foley might be appropriate for I/Os. More fuel for your care plan fodder. Address all the main issues and your instructor will be impressed. You already have a good start. I love care planning.