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Category Archives: Cardio, GI & Respi

Knowledge Deficit — Liver Cirrhosis

LC-Knowledge Deficit

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NURSING DIAGNOSIS: Knowledge Deficit

May be related to
  • Lack of exposure/recall; information misinterpretation
  • Unfamiliarity with information resources
Possibly evidenced by
  • Questions; request for information, statement of misconception
  • Inaccurate follow-through of instructions/development of preventable complications
Desired Outcomes
  • Verbalize understanding of disease process/prognosis, potential complications.
  • Correlate symptoms with causative factors.
  • Identify/initiate necessary lifestyle changes and participate in care.

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Disturbed Body Image/Self-Esteem — Liver Cirrhosis

LC-Disturbed Body Image

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NURSING DIAGNOSIS: Self-Esteem/Body Image disturbed

May be related to
  • Biophysical changes/altered physical appearance
  • Uncertainty of prognosis, changes in role function
  • Personal vulnerability
  • Self-destructive behavior (alcohol-induced disease)
Possibly evidenced by
  • Verbalization of change/restriction in lifestyle
  • Fear of rejection or reaction by others
  • Negative feelings about body/abilities
  • Feelings of helplessness, hopelessness, or powerlessness
Desired Outcomes
  • Verbalize understanding of changes and acceptance of self in the present situation.
  • Identify feelings and methods for coping with negative perception of self.

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Risk for Acute Confusion — Liver Cirrhosis

LC-Risk for Confusion

NURSING DIAGNOSIS: Confusion, risk for acute

Risk factors may include
  • Alcohol abuse
  • Inability of liver to detoxify certain enzymes/drugs
Desired Outcomes
  • Maintain usual level of mentation/reality orientation.
  • Initiate behaviors/lifestyle changes to prevent or minimize recurrence of problem.

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Risk for Injury — Liver Cirrhosis

NURSING DIAGNOSIS: Injury, risk for [hemorrhage]

LC-Risk for Injury
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Risk factors may include
  • Abnormal blood profile; altered clotting factors (decreased production of prothrombin, fibrinogen, and factors VIII, IX, and X; impaired vitamin Kabsorption; and release of thromboplastin)
  • Portal hypertension, development of esophageal varices
Desired Outcomes
  • Maintain homestasis with absence of bleeding
  • Demonstrate behaviors to reduce risk of bleeding.

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Ineffective Breathing Pattern — Liver Cirrhosis

NURSING DIAGNOSIS: Breathing Pattern, risk for ineffective

LC-Ineffective Breathing Pattern
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Risk factors may include
  • Intra-abdominal fluid collection (ascites)
  • Decreased lung expansion, accumulated secretions
  • Decreased energy, fatigue
Desired Outcomes
  • Maintain effective respiratory pattern; be free of dyspnea and cyanosis, with ABGs and vital capacity within acceptable range.

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Impaired Skin Integrity — Liver Cirrhosis

NURSING DIAGNOSIS: Skin Integrity, risk for impaired

LC-Impaired Skin Integrity
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Risk factors may include
  • Altered circulation/metabolic state
  • Accumulation of bile salts in skin
  • Poor skin turgor, skeletal prominence, presence of edema, ascites
Desired Outcomes
  • Maintain skin integrity.
  • Identify individual risk factors and demonstrate behaviors/techniques to prevent skin breakdown.

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Excess Fluid Volume — Liver Cirrhosis

NURSING DIAGNOSIS: Fluid Volume excess

LC-Fluid Volume Excess
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May be related to
  • Compromised regulatory mechanism (e.g., syndrome of inappropriate antidiuretic hormone [SIADH], decreased plasma proteins, malnutrition)
  • Excess sodium/fluid intake
Possibly evidenced by
  • Edema, anasarca, weight gain
  • Intake greater than output, oliguria, changes in urine specific gravity
  • Dyspnea, adventitious breath sounds, pleural effusion
  • BP changes, altered CVP
  • JVD, positive hepatojugular reflex
  • Altered electrolyte levels
  • Change in mental status
Desired Outcomes
  • Demonstrate stabilized fluid volume, with balanced I&O, stable weight, vital signs within patient’s normal range, and absence of edema.

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NCP Imbalanced Nutrition — Liver Cirrhosis

Nursing Diagnosis: Nutrition: imbalanced, less than body requirements

LC-Imbalanced Nutrition
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May be related to
  • Inadequate diet; inability to process/digest nutrients
  • Anorexia, nausea/vomiting, indigestion, early satiety (ascites)
  • Abnormal bowel function
Possibly evidenced by
  • Weight loss
  • Changes in bowel sounds and function
  • Poor muscle tone/wasting
  • Imbalances in nutritional studies
Desired Outcomes
  • Demonstrate progressive weight gain toward goal with patient-appropriate normalization of laboratory values.
  • Experience no further signs of malnutrition.

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Liver Cirrhosis Nursing Care Plans

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Cirrhosis is a chronic disease of the liver characterized by alteration in structure, degenerative changes and widespread destruction of hepatic cells, impairing cellular function and impeding blood flow through the liver. Causes include malnutrition, inflammation (bacterial or viral), and poisons (e.g., alcohol, carbon tetrachloride, acetaminophen). Cirrhosis is the fourth leading cause of death in the United States among people ages 35 to 55 and represents a serious threat to long-term health.

Below are 8 nursing care plans for liver cirrhosis.

8 Liver Cirrhosis Nursing Care Plans

  1. Imbalanced Nutrition — Liver Cirrhosis
  2. Excess Fluid Volume — Liver Cirrhosis
  3. Impaired Skin Integrity — Liver Cirrhosis
  4. Ineffective Breathing Pattern — Liver Cirrhosis
  5. Risk for Injury — Liver Cirrhosis 
  6. Risk for Acute Confusion — Liver Cirrhosis
  7. Disturbed Body Image/Self-Esteem — Liver Cirrhosis
  8. Knowledge Deficit — Liver Cirrhosis 

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NCP Decreased Cardiac Output — Heart Failure (CHF)

 

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NURSING DIAGNOSIS: Cardiac Output, decreasedMay be related to

  • Altered myocardial contractility/inotropic changes
  • Alterations in rate, rhythm, electrical conduction
  • Structural changes (e.g., valvular defects, ventricular aneurysm)

Possibly evidenced by

  • Increased heart rate (tachycardia), dysrhythmias, ECG changes
  • Changes in BP (hypotension/hypertension)
  • Extra heart sounds (S3, S4)
  • Decreased urine output
  • Diminished peripheral pulses
  • Cool, ashen skin; diaphoresis
  • Orthopnea, crackles, JVD, liver engorgement, edema
  • Chest pain

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