Not sure what nursing diagnosis to use.

[DesireeStudent]

Patient has hx of cirrhosis and admitted with liver failure. Has a hx of hypertension as well. On assessment noted that patient was cool to touch, had pedal pulses of +1, he was pale and his body was jaundiced. (a light yellowing of the skin was evident, he was a light skin male). He had no other edema, but mild ascites in abdominal area which was distended. I am having trouble with coming up with a correct diagnosis to define his cirulation problems. I have so far decided that he has:

Risk for ineffective gastrointesinal perfusion r/t liver dysfunction.

Is there anything else i am missing...any connection??

[Esme12, ASN, BSN, RN]

the biggest thing about a care plan is the assessment. the second is knowledge about the disease process. of....first to write a care plan there needs to be a patient, a diagnosis, an assessment of the patient which includes tests, labs, vital signs, patient complaint and symptoms. let me try to help you. there are many nurses here and many who came before me to this site but one nurse stands out.....daytonite(rip) https://allnurses.com/general-nursing...ns-286986.htmlyou can also use the search on this site to lead you to care plans.

daytonite.

care plan basics:

every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the nanda taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. you need to have access to these books when you are working on care plans. there are currently 188 nursing diagnoses that nanda has defined and given related factors and defining characteristics for. what you need to do is get this information to help you in writing care plans so you diagnose your patients correctly.

don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. these will become their symptoms, or what nanda calls defining characteristics.

here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adls, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)
   

a care plan is nothing more than the written documentation of the nursing process you use to solve one or more of a patient's nursing problems. the nursing process itself is a problem solving method that was extrapolated from the scientific method used by the various science disciplines in proving or disproving theories. one of the main goals every nursing school wants its rns to learn by graduation is how to use the nursing process to solve patient problems.

care plan reality: the foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. what is happening to them could be a medical disease, a physical condition, a failure to be able to perform adls (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. therefore, one of your primary aims as a problem solver is to collect as much data as you can get your hands on. the more the better. you have to be a detective and always be on the alert and lookout for clues. at all times. and that is within the spirit of step #1 of this whole nursing process.

assessment is an important skill. it will take you a long time to become proficient in assessing patients. assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. history can reveal import clues. it takes time and experience to know what questions to ask to elicit good answers. part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. but, there will be times that this won't be known. just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

a nursing diagnosis standing by itself means nothing. the meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient. in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are.

what i would suggest you do is to work the nursing process from step #1. take a look at the information you collected on the patient during your physical assessment and review of their medical record. start making a list of abnormal data which will now become a list of their symptoms. don't forget to include an assessment of their ability to perform adls (because that's what we nurses shine at). the adls are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. what is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list. this is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

care plan reality: is actually a shorthand label for the patient problem. the patient problem is more accurately described in the definition of this nursing diagnosis (every nanda nursing diagnosis has a definition). thanks daytonite

now what is cirrhosis. what does is do to the patient? do they have a fluid overload or deficit? what is the ammonia level? are they alert? why does the patient have cirrhosis? are they still drinking? will the possibly go through dt's? liver failure patient itch a lot.....is their skin integrity intact? do the have a knowlege deficit about their disease or addiction issues (if drinking). they usually do have imbalance nutrition but why? poor eating habits? can't eat enough due to ascities? nausea, vomiting due to alterede hepatic function or inadequate bile production? does the patients safety come into play? can the perform adl's independently? do they have a steady gait?

nursing care plan | nursing crib

nursing care plan

nursing resources - care plans

understanding the essentials of critical care nursing

nursing care plans, care maps and nursing diagnosis

http://www.delmarlearning.com/compan.../apps/appa.pdf

cns: problem oriented nursing care plans

i hope this helped. :)

[DesireeStudent]

Thank you esme12. I have all of my care plan completed with most if not all of what you have written here. I am just stumped as to how i can define the circulation problem only. I have thirteen diagnoses for this patient, which have all been ok'ed by by instructor, except for this one...i am not sure how to explain cold extremities and weak pedal pulses as part of having liver failure or if this is his hypertension....and if so how does ineffective tissue perfusion work in all of this.

[Esme12, ASN, BSN, RN]

Ok.......it is really helpful to let us know what you have done

Thermography demonstrates that patients with advanced liver cirrhosis have cool peripheries, with skin pallor and poor capillary perfusion. Indeed, in clinical questionnaires, patients with cirrhosis are more likely to complain of cold hands. high cardiac output and systemic hypotension relate to the marked and dysregulated splanchnic vasodilatation consequent on the development of liver cirrhosis, and as a result of portal hypertension. Hepatic fibrosis causes a marked impairment of portal blood flow into the liver, and maladaptive splanchnic vasodilatation attempts to rectify the associated reduction in hepatic perfusion by increasing blood flow and pressure in the portal venous system. However, rather than increasing perfusion of the liver, this hyperaemia and hypertension results in incremental shunting of portal blood Hyperdynamic circulation in liver cirrhosis: not peripheral vasodilatation but

Think poor perfsuion, poor nutrition, poor cardiac ability to compensate, the ascities poor nutrition

[nurseprnRN, BSN, RN]

"risk for ineffective gastrointestinal perfusion r/t liver dysfunction."

what you are saying here is that he might develop bad gi perfusion (which is arterial flow) because he has a bad liver. i'm not sure that's where you are going with your assessment. the article suggests that because there's so much circulating volume tied up in dilated blood vessels, the periphery suffers. i dunno. beyond that, i'm not seeing anything nursing can do for him that would reduce his risk of poor gi perfusion.

liver failure people lose a lot of circulating volume into their bellies in the form of ascites, because their livers leak protein-filled fluid out there, driven by the high blood pressures in the cirrhotic liver-- think of trying to force water through a very small, stiff hose. that makes them hypovolemic, which decreases cardiac output and makes their extremities cold.

also, all that fluid in there soaks up a lot of metabolic energy in the form of heat. we teach people in cold-weather camping to get up and pee as soon as they feel the need, in part because it never gets better and in part because you are wasting metabolic energy to keep that urine warm. that's a big metabolic workload to shoulder. you could be sure that you give him exogenous sources of heat to decrease that metabolic work.

also, all that protein leaving their circulation amounts to protein malnutrition. you can tap that ascites, sure you can, but a rip-roaring bad liver will make liters of that in a day, so all you're doing is making his belly smaller temporarily, and unless you put a lot more fluid and protein back into his vascular space, he'll just dry up and blow away. and he'll still lose all your replacement again into ascites overnight.

perhaps you could look at him as at increased risk for injury, peripheral tissue breakdown, related to liver failure with loss of serum proteins into the ascites resulting in protein malnutrition and decreased arterial circulation due to loss of circulating volume. your interventions would be aimed at protecting his peripheral tissues from injury.

the only other thing i could think of in terms of circulation per se would be the risk of humongous (technical term there ) gi hemorrhage from esophageal varices, which is the way most of these people die. there's only so much you can do about that-- avoiding valsalva, avoiding hard crunchy things po, avoid nausea and vomiting, and i can't think of much else. sometimes the gi docs can sclerose them endoscopically. if they have already bled once, they may have balloon-ended tubes down there, attached to traction (by being tied tight to the mask on a football helmet) to keep compression on the varices until they stop. i've never actually seen that work for longer than the real short term.

esme, old friend, whaddaya think?.