NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Gastrointestinal System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Intestinal Disorders

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Malignant Tumors of the Intestine

Focus topic: Medical–Surgical Nursing

Characteristics
A. Adenocarcinoma of the duodenum is the most common lesion of the small intestines.

  • In the United States, less than 1% of gastrointestinal tract cancers (CA) arise in the small bowel.
  • Occurs in younger age group; twice as common in men.

B. Malignant tumors of large intestine are second most frequent cause of death from cancer.

  • Men and women equally affected.
  • CA colon more common in women; CA rectum more common in men.
  • Metastasis is by direct extension, usually to stomach from transverse colon, bladder, and bowel.

Assessment
A. Assess for abnormal stools, malabsorption, intestinal bleeding.
B. Assess for weight loss, malaise, anemia.
C. Check for anorexia.
D. Check for vomiting.
E. Evaluate cramplike pain.
F. Assess for intestinal obstruction or biliary obstruction.

Implementation

A. Provide postoperative care for surgical intervention.

  • Large intestine tumors may result in a colostomy.
  • Instruct client in colostomy procedure and care.
  • Refer client to ostomy club.

B. Monitor cytotoxic drug therapy following surgery.
C. Provide psychological support.
D. Maintain low-residue or liquid diet.
E. Administer antibiotics if ordered.

Surgical Corrections for the Colon

Medical–Surgical Nursing: Appendicitis

Focus topic: Medical–Surgical Nursing

Definition: An inflammation of the appendix due to infection; can be classified as simple, gangrenous, or perforated.

Assessment
A. Assess for generalized, severe upper abdominal or periumbilical pain that localizes in the right lower quadrant.
B. Check for rebound tenderness or flatus.
C. Check for anorexia.
D. Evaluate slightly increased temperature.
E. Assess for nausea and vomiting.
F. Assess for abdominal distention and, if ruptured, paralytic ileus.
G. Check diagnostic tests: elevated white blood cells (WBC), urinalysis, abdominal x-rays and ultrasound.

Implementation
A. Place in semi-Fowler’s position to relieve abdominal strain.
B. Give nothing by mouth until bowel sounds present. IV fluids may be given to maintain vascular volume.
C. Give antibiotics (third-generation cephalosporin) as ordered.
D. Insert nasogastric tube as required; rectal tube for flatus.
E. Client should not receive laxatives or enemas because these may perforate the appendix.
F. Follow routine postoperative nursing care for any abdominal surgery (return of bowel sounds).
G. Surgery may be laparoscopic.

Medical–Surgical Nursing: Intestinal Obstruction

Focus topic: Medical–Surgical Nursing

Definition: An impairment of the forward flow of intestinal contents caused by partial or complete stoppage.

Characteristics
A. Mechanical type of obstruction.

  • Adhesions—fibrous bands of scar tissue, following abdominal surgery, may become looped over a portion of the bowel.
  • Hernias—incarcerated or strangulated.
  • Volvulus—twisting of the bowel.
  • Intussusception—telescoping of the bowel upon itself.
  • Tumors.
  • Hematoma.
  • Fecal impaction.
  • Intraluminal obstruction.

B. Neurogenic type of obstruction.

  • Paralytic, adynamic ileus.
  • Ineffective peristalsis due to toxic or traumatic disturbance of the autonomic nervous system.

C. Vascular type of obstruction.

  • Occlusion of the arterial blood supply to the bowel.
  • Mesenteric thrombosis.
  • Abdominal angina.

D. Pathophysiology.

  • Fluids and air collect proximal to the obstruction.
    a. Peristalsis increases as the bowel attempts to force material through.
    b. Peristalsis ends and the bowel becomes blocked.
  • Pressure increases in the bowel and decreases the absorptive ability.
  • Circulating blood volume is reduced and shock may develop.
  • Location of the obstruction determines the symptoms and progression of the clinical course.

Assessment
A. Assess for small bowel obstruction (mortality is 10%) by evaluating following symptoms:

  • Cramplike, colicky pain in midabdomen may be intermittent.
  • Nausea and early severe vomiting.
  • Reverse peristalsis.
  • Dehydration; signs of fluid and electrolyte imbalance.
  • Abdominal distention.
  • Shock and death.

B. Assess for large bowel obstruction by evaluating following symptoms:

  • Progression of symptoms is slower than with small bowel obstruction.
  • Constipation.
  • Abdominal distention.
  • Cramplike pain in lower abdomen.
  • If ileocecal valve is incompetent, relief of colonic pressure occurs by reflux into the ileum.

C. Assess for paralytic ileus by evaluating following symptoms:

  • Dull, diffused pain.
  • Gaseous distention.
  • Bowel sounds diminished or absent.
  • Vomiting after eating.

D. Observe and report the nature, duration, and character of pain.
E. Assess the presence and progression of distention and the absence of flatus and stool.
F. Observe for signs and symptoms of fluid and electrolyte imbalance.
G. Note lab test results: elevated hematocrit, blood urea nitrogen (BUN) and blood glucose, and low potassium.

Implementation
A. Assist in placement of a long intestinal tube with weighted or balloon tip for intestinal decompression to remove gas and fluid.
B. Monitor parenteral fluids to replace fluids and electrolytes.

  • Sodium, potassium, and chloride.
  • Dextrose and water.

C. Administer antibiotics to prevent secondary infections (especially peritonitis).
D. Measure and record vital signs, intake and output (urinary output hourly—keep at 30 mL/hr or more), and emesis.
E. Save stool for testing.
F. Prepare client for surgery, if indicated.

Medical–Surgical Nursing: Herniorrhaphy

Focus topic: Medical–Surgical Nursing

Definition: A hernia is a protrusion of the intestine through an opening in the abdominal wall.

Characteristics
A. Femoral—below groin.
B. Umbilical—around umbilicus, due to failure of orifice to close after birth.
C. Incisional—due to weakness in incisional area from infection or poor healing.
D. Inguinal—weakness in abdominal wall where round ligament is located in female and where spermatic cord emerges in male.

Assessment
A. Assess for possible wound healing at incision site.
B. Assess for edematous scrotum for inguinal hernia.
C. Check for constipation.
D. Assess for abdominal distention.

Implementation
A. Treatment.

  • Reducing hernia—place an appliance over hernia area to prevent abdominal contents from entering hernia area and strangulating.
  • Surgical intervention.

B. Postoperative care.

  • Maintain routine postoperative care.
  • Ambulate day of surgery or next morning.
  • Provide ice pack or scrotal support if inguinal hernia in male.
  • Prevent urine retention.
  • Report any abdominal distention.

Medical–Surgical Nursing: Diverticulosis and Diverticulitis

Focus topic: Medical–Surgical Nursing

Definition: Diverticulum is the out pouching of intestinal mucosa, which may occur at any point in the gastrointestinal tract but more commonly in the sigmoid colon. It is caused by congenital weakness and increased pressure in the lumen. Diverticulosis is the presence of multiple diverticula. Diverticulitis is inflammation of diverticula.

Characteristics
A. No symptoms unless complications develop.
B. Large bowel diverticula are more apt to develop complications.
C. Complications are perforation, hemorrhage, inflammation, fistulas, and abscess.

Assessment
A. Assess for cramplike pain (usually left-sided).
B. Check for flatulence.
C. Assess for nausea and vomiting.
D. Evaluate patterns of irregularity, irritability, and spasticity of the intestine.
E. Assess for fever.
F. Examine for dysuria associated with bladder involvement.

Implementation
A. Provide care during acute phase.

  • Intravenous fluids with electrolytes.
  • Bed rest.
  • Nothing by mouth (NPO).
  • Nasogastric decompression.
  • Drugs: antibiotics, analgesics, antispasmodics, and bulk former (Metamucil).

B. Monitor appropriate diet.

  • Current studies indicate a high-fiber diet to increase stool bulk and reduce spasms. (Use bran fiber for diverticulosis.)
  • Bowel rest and low-fiber regimen for severe inflammatory phase of diverticulitis.
  • Provide vitamin and iron supplements.

C. Instruct client and family in pathology and rationale for treatment.
D. Provide pain medication (Talwin [pentazocine]) rather than morphine sulfate (MS) or Demerol (pethidine), which increase colonic pressure.
E. Monitor stool normalization: bowel lubricant nightly, stool softener, bulk preparation daily, evacuant suppository, vegetable oil, unprocessed bran, and fruit juice daily.
F. Prepare client for surgery if indicated.

Medical–Surgical Nursing: Hemorrhoids

Focus topic: Medical–Surgical Nursing

Definition: Dilated varicose veins of the anal canal that may be internal or external.

Characteristic
A. Types.

  • Internal hemorrhoids (occur above the internal sphincter)—covered by mucous membrane.
  • External hemorrhoids (occur outside the external sphincter)—covered by anal skin.
  • Thrombosed hemorrhoids are infected and clotted.

B. Causes.

  • Portal hypertension.
  • Straining from constipation.
  • Irritation and diarrhea.
  • Increased venous pressure from congestive heart failure.
  • Increased abdominal pressure as from pregnancy.

Assessment
A. Assess for itching.
B. Assess for pain.
C. Check for bleeding.
D. Assess for complications: hemorrhage, strangulation, thrombosis, and prolapse.

Implementation
A. Treat constipation with diet, stool softeners, and laxatives.
B. Maintain diet low in roughage and high in fiber.
C. Provide suppositories, ointments, and systemic analgesics.
D. Administer hot sitz baths.

E. Surgical treatment.

  • Internal hemorrhoids ligated with rubber bands—tissue becomes necrotic and drops off.
  • Cryosurgical hemorrhoidectomy may be done.

F. Nonsurgical treatment.

  • Infrared photocoagulation and laser therapy.
  • Methods affix mucosa to underlying muscle.

Medical–Surgical Nursing: Anorectal Surgery

Focus topic: Medical–Surgical Nursing

Characteristics
A. Pilonidal cyst—cyst located on lower sacrum with hair protruding from sinus opening.
B. Anal fissure—crack in the anal canal.
C. Anal fistula—abnormal opening near the anus and continuing into the anal canal.

Implementation
A. Give routine postoperative care.
B. Keep perineal and rectal area clean by providing sitz baths three to four times/day (after first day) or irrigations.
C. Apply spray analgesics when needed to ease pain.
D. Medicate for pain but avoid codeine preparations as they are constipating.
E. Place in prone position or side-lying position for at least 4 hours postop to prevent hemorrhage.
F. Prevent urinary retention.

  • Keep accurate intake and output.
  • Observe for frequent, small voidings.

G. Clients usually have packing inserted with pressure dressing applied.

  • Reinforce dressing as needed to apply pressure.
  • Keep area clean.

H. Apply ice packs over rectal dressing immediately postoperatively.

  • Prevents edema formation.
  • Provides vasoconstriction.

I. When client is able to ambulate, encourage small steps; increase activity gradually.
J. When client is sitting in chair, use flotation pads, not rubber rings; limit sitting to short periods of time.
K. Force fluids to aid in keeping bowel movements soft.
L. Administer stool softeners and laxatives every day.
M. On second day, before first bowel movement, enemas are sometimes ordered.

  • Medicate for pain.
  • Administer an enema with a pliable, soft, welllubricated tube.
  • Place in sitz bath after expelling enema (will relieve excessive pain by relaxing anal area).

Medical–Surgical Nursing: Disorders of Liver, Biliary, and Pancreatic Function

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Diagnostic Evaluation Studies

Focus topic: Medical–Surgical Nursing

Physical Examination
A. Palpation of the abdomen to determine tenderness, size, and shape of liver and spleen.
B. Visual inspection for ascites, venous networks, and jaundice.

Radiologic Techniques
A. Cholecystogram—to visualize the gallbladder for detection of gallstones, and to determine the ability of the gallbladder to fill, concentrate, contract, and empty normally. Used only if ultrasound is not conclusive as in acalculous cholecystitis.

  • Organic radiopaque dye may be given by mouth 10–12 hours before x-ray, or intravenously 10 minutes before x-ray.
  • Dyes taken orally (e.g., Telepaque [iopanoic acid], Priodax [iodoalphionic acid], Oragrafin [sodium ipodate]) are given one at a time at 3-to 5-minute intervals with at least 240 mL of water. A low-fat evening meal precedes the dye ingestion. Clients are NPO until after examination. An enema is given before the test.

B. Cholangiography—radiopaque dye is injected directly into the biliary tree.

  • May be injected into the common duct drain during surgery or postoperatively.
  • Gallbladder disease is indicated by poor or absent visualization of the gallbladder.
  • Stones will appear as shadows within the opaque medium.

C. Scanning of the liver—131-iodine or other like substances are administered intravenously; then a scintillation detector is passed over the area.

  • Lesions appear as filling defects.
  • The isotopes are concentrated in functioning tissue.

D. Other procedures with contrast media: celiac angiography, hepatoportography, splenoportography, and pancreatic angiography.

  • With all of these procedures, organic iodine dye is injected into the vessel, flowing to and outlining the desired area.
  • Reveals the patency of the vessels and the lesions that distort the vasculature.

Liver Biopsy
A. Sampling of liver tissues by needle aspiration through abdominal wall to determine anatomic tissue changes and to facilitate diagnosis.

B. Nursing implementation prior to procedure.

  • Verify test results of prothrombin times (PT) and blood typing; high PT may indicate deficiency in prothrombin, fibrinogen, or factor V, VII, or X. Administer vitamin K as ordered.
  • Obtain baseline vital signs and consent form.
  • Keep NPO and provide sedation as ordered.
  • Assemble equipment, have client empty bladder, place client in supine position on right side of bed.
  • Support client; let client verbalize fears.

C. Nursing implementation following procedure.

  • Position client on right side over biopsy site to prevent hemorrhage.
  • Measure and record vital signs.
  • Watch for shock.
  • Observe for complications: hemorrhage, puncture of the bile duct, peritonitis, and pneumothorax.

Laboratory/Radiographic/Diagnostic Assessment for Liver Disease

Medical–Surgical Nursing

Medical–Surgical Nursing: Jaundice

Focus topic: Medical–Surgical Nursing

Definition: A symptom of a disease that results in yellow pigmentation of the skin due to accumulation of bilirubin pigment. Jaundice is usually first observed in the sclera of the eye.

Characteristics
A. Hemolytic.

  • Results from the rapid rate of red blood cell destruction, which releases excessive amounts of unconjugated bilirubin.
  • Caused by hemolytic transfusion reactions, erythroblastosis fetalis, and other hemolytic disorders.

B. Hepatocellular.

  • Results from the inability of the diseased liver cells to clear the normal amount of bilirubin from the blood.
  • Caused by viral liver cell necrosis or cirrhosis of the liver.

C. Obstructive.

  • Caused by intrahepatic obstruction due to inflammation, tumors, or cholestatic agents.
  • Bile is dammed into the liver substance and reabsorbed into the blood.
  • Deep-orange, foamy urine; white- or claycolored stools; and severe itching (pruritus).

Assessment
A. Evaluate laboratory findings indicating hemolytic jaundice.

  • Increased indirect (unconjugated) serum bilirubin.
  • Absence of bilirubin in urine.
  • Increased urobilinogen levels.

B. Evaluate laboratory findings indicating hepatocellular jaundice.

  • Increased bilirubin.
  • Increased serum glutamic-oxaloacetic transaminase (SGOT).
  • Increased serum glutamic pyruvic transaminase (SGPT).
  • Increased alkaline phosphatase.
  • Urobilinogen in urine.
  • Increased PT.
  • Decreased albumin.

C. Evaluate laboratory findings indicating obstructive jaundice.

  • Increased bilirubin.
  • Increased alkaline phosphatase.
  • Decreased stool urobilinogen.

Implementation
A. Control pruritus.

  • Starch or baking soda baths.
  • Soothing lotions, such as calamine.
  • Antihistamines, tranquilizers, and sedatives.
  • Questran (cholestyramine)—binds bile salt.

B. Provide emotional support.

  • Allow client to ventilate feelings of altered body image.
  • Notify family and visitors of client’s appearance.

C. Provide dietary plan for anorexia and liver involvement.

Medical–Surgical Nursing: Viral Hepatitis

Focus topic: Medical–Surgical Nursing

Definition: An inflammation of the liver; the most common infection of the liver, often becoming a major health problem in crowded living conditions. Through vaccination, types A (two vaccines—Havrix and Vaqta) and B can be prevented.

Characteristics
A. Hepatitis A (HAV); formerly infectious hepatitis.

  • Transmission.
    a. Oral–anal route, especially in conditions of poor hygiene.
    b. Blood transfusion with infected serum or plasma.
    c. Contaminated equipment, such as syringes and needles.
    d. Contaminated milk, water, and food (uncooked clams and oysters).
    e. Respiratory route is possible, but not yet established.
    f. Antibodies persist in serum.
    g. Intimate contact with carriers of the virus.
  • Prevention.
    a. Good hand washing and good personal hygiene.
    b. Do not eat uncooked shellfish (clams, oysters).
    c. Control and screening of food handlers.
    d. Passive immunization.
    (1) Immune serum globulin (ISG) to exposed individuals.
    (2) ISG for prophylaxis for travelers to developing countries.
  • Incubation period: 20–50 days (short incubation period).
  • Incidence.
    a. More common in fall and winter months.
    b. Usually found in children and young adults.
    c. Client is infectious 3 weeks prior to and 1 week after developing jaundice.
  • Clinical recovery: 3–16 weeks.

B. Hepatitis B (HBV); formerly serum hepatitis (SH) virus.

  • Transmission.
    a. Oral or parenteral route with infusion, ingestion, or inhalation of the blood of an infected person.
    b. Contaminated equipment such as needles, syringes, and dental instruments.
    c. Oral or sexual contact.
    d. Infected people can become carriers.
    e. Infected by filterable virus—Australian antigen.
  • Prevention.
    a. Screen blood donors for HB3Ag.
    b. Use disposable needles and syringes.
    c. Registration of all carriers.
    d. Passive immunization: ISG for exposure and hepatitis B immunoglobulin (HBIG) for finger stick, contact with mucous membrane secretions.
    e. Active immunization: Heptavax (hepatitis B vaccine) and formalin-treated hepatitis B vaccine—purified antigen given in three doses (initial dose, 1 month, then 6 months).
  • Incubation: 45–180 days.

C. Hepatitis C (HCV); formerly non-A, non-B.

  • Transmission.
    a. Transmitted primarily by contact with contaminated blood.
    b. Incidence noted following injection of prophylactic gamma globulin.
    c. Increased incidence in population using drugs.
  • Usual incubation period 14–180 days.
  • May not show clinical jaundice—only 30–40% of clients have symptoms.

D. Hepatitis D (delta agent).

  • Transmission.
    a. Same as hepatitis B.
    b. Only clients with hepatitis B are at risk for hepatitis D because it requires B surface antigen for replication.
  • Infections occur as coinfection with HBV or superinfection in HBV carrier.
  • Incubation period: 45–180 days.

E. Hepatitis E.

  • Rare in United States but epidemic in areas of India.
  • Transmitted through oral–fecal route by contaminated foods or water.
  • Course of illness resembles hepatitis A.
  • Incubation period: 15–60 days.

F. Hepatitis G—newly discovered, believed to be transmitted by infected blood. May exist only as a coinfection with HCV.

Assessment
A. Perform general assessment; keep in mind that client is not immediately sick after being infected; onset depends on incubation period and degree of infection.
B. Assess preicteric phase.

  • Signs are generally systemic.
    a. Lethargy and malaise.
    b. Anorexia, nausea and vomiting.
    c. Headache.
    d. Abdominal tenderness and pain.
    e. Diarrhea or constipation.
    f. Low-grade fever.
    g. Myalgia and polyarthritis.
  • Aforementioned symptoms may precede jaundice or it may never appear.

C. In anicteric hepatitis, client has symptoms of disease and altered lab tests, but no jaundice.
D. Assess icteric phase.

  • Dark urine and clay-colored stools generally occur a few days prior to jaundice.
  • Jaundice is first observable in the eyes.
  • Pruritus—usually transient and mild.
  • Enlarged liver with tenderness.
  • Nausea may continue with dyspepsia and flatulence.

E. Assess posticteric phase.

  • Jaundice disappears.
  • The absence of clay-colored stools is an indication of resolution.
  • Fatigue and malaise continue.
  • Enlarged liver continues for several weeks.

Implementation
A. Type A.

  • Wash your hands carefully, always wear gloves, and take precautions during stool and needle procedures.
  • Use disposable equipment or sterilized reusable equipment.
  • Provide diet.
    a. High-calorie, well-balanced diet; modified servings according to client response.
    b. Protein decreased if signs of coma.
    c. 10% glucose IV if not taking oral foods.
    d. Vitamin K supplements if prothrombin time is abnormally long.
    e. Promote adequate fluid intake.
  • Instruct client and family.
    a. Stress the importance of follow-up care.
    b. Stress the restricted use of alcohol.
    c. Stress that client never offers to be a blood donor.
    d. Encourage gamma globulin for close contacts.
    e. Advise correction if any unsanitary condition exists in the home.
  • Bed rest during acute phase with bathroom privileges; reasonable activity level during subsequent phases.

B. Type B.

  • Maintain bed rest until symptoms have decreased.
  • Alpha-interferon daily injections for 4 months induce remission in one-third of clients.
  • Provide well-balanced diet supplemented with vitamins. Protein may be restricted.
  • Administer antacids for gastric acidity and soporifics for rest and relaxation.
  • Instruct client and family in pathology of the disease and rationale for treatment.
  • Counsel client to abstain from sexual activity during communicable period.

C. Other types of hepatitis follow the treatment principles for HAV and HBV.

Medical–Surgical Nursing: Cirrhosis

Focus topic: Medical–Surgical Nursing

Definition: Cirrhosis is a progressive disease of the liver characterized by diffuse damage to the cells with fibrosis and nodular regeneration.

Characteristics
A. Types.

  • Alcoholic or Laënnec’s cirrhosis.
    a. Most common in the United States.
    b. Scar tissue surrounds the portal areas.
    c. Characterized by destruction of hepatic tissue, increased fibrous tissue, and disorganized regeneration.
  • Posthepatic cirrhosis—a sequela to viral hepatitis in which there are broad bands of scar tissue. Results from chronic hepatitis B or C or unknown cause.
  • Biliary cirrhosis.
    a. Pericholangitic scarring as a result of chronic biliary obstruction and infection.
    b. Least encountered of the three types.

B. Causes.

  • Repeated destruction of hepatic cells, replacement with scar tissue, and regeneration of liver cells.
  • Insidious onset with progression over a period of years.
  • Occurs twice as often in males; primarily affects 40- to 60-year-old age group.

C. Clinical progression.

  • Early in the disease process, the liver becomes enlarged due to fat accumulation in the cells; accompanying this are gastrointestinal problems and fever.
  • Subsequent symptoms are usually anorexia, weight loss, fatigue, and jaundice. (Jaundice is not always present in the active stage.)
  • Continued structural changes in the liver result in obstruction of portal circulation. Collateral circulation increases to compensate for increased portal pressure.
    a. Obstruction of portal circulation results in portal hypertension, which in turn leads to esophageal varices and changes in bowel functioning with chronic dyspepsia.
    b. Liver function deteriorates; leads to peripheral edema and ascites, accompanied by hormone imbalance, weakness, depression, and potential bleeding.
  • As the liver is unable to synthesize protein, plasma albumin is reduced; leads to edema and contributes to ascites.
    a. Ascites, accumulation of serous fluid in the peritoneal cavity, increases as pressure in the liver increases.
    b. In addition, estrogen–androgen imbalance causes increased sodium and water to be retained.
  • Hepatic coma results from the incomplete metabolism of nitrogenous compounds, particularly ammonia, by the incompetent liver.
  • When the liver cannot detoxify this product, it remains in the systemic circulation, and hepatic encephalopathy ensues.
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Assessment
A. Evaluate client’s history of failing health, weakness, gastrointestinal distress, fatigue, weight loss, and low resistance to infections.
B. Assess for emaciation and ascites due to malnutrition, portal hypertension, and hypoalbuminemia.
C. Check for hematemesis.
D. Assess for lower leg edema from ascites obstructing venous return from legs.
E. Palpate liver.
F. Assess for prominent abdominal wall veins from collateral vessel bypass.
G. Assess for esophageal varices and hemorrhoids from portal hypertension.
H. Evaluate skin manifestations: spider angiomas, telangiectasia, vitamin deficiency, and alterations.
I. Evaluate laboratory tests.

  • Impaired hepatocellular function; elevated bilirubin, aspartate aminotransferase (AST) (SGOT), alanine transaminase (ALT) (SGPT), and lactate dehydrogenase (LDH); reduced bromosulfophthalein (BSP); reduced albumin; elevated PT.
  • Increased WBC, decreased red blood cells (RBC), coagulation abnormalities, increased gamma globulin, and proteinuria.

J. Assess for precoma state: tremor, delirium, and dysarthria.

Implementation
A. Assist in maximizing liver function.

  • Diet: ample protein to build tissue; carbohydrates to sustain weight and provide energy.
  • With edema, restrict salt and fluids. With low Na, unrestricted fluids could lead to low serum Na and electrolyte imbalance.
  • Multivitamin supplement (especially B complex).
  • Diuretics (spironolactones) potassium-sparing to decrease ascites.
  • Antacids decrease gastric distress and minimize possibility of bleeding.

B. Eliminate hepatotoxin intake (aldosterone antagonist).

  • Completely restrict use of alcohol.
  • Lower the dosage of drugs metabolized by the liver.
  • Avoid sedatives and opiates.
  • Avoid all known hepatotoxic drugs (Thorazine [chlorpromazine], Fluothane [halothane]).
  • Colchicine (anti-inflammatory drug to treat gout) has been shown to increase survival time.

C. Prevent infection by adequate rest, diet, and environmental control.
D. Administer plasma proteins as ordered.
E. Maintain adequate rest during acute phase to reduce demand on the liver.
F. Monitor intake and output due to fluid restriction.
G. Provide good skin care and control pruritus.
H. Evaluate client’s response to diet therapy.
I. Measure, record, and compare vital signs.

  • Character of pain.
  • Progression of edema.
  • Character of emesis and stools.

J. Evaluate level of consciousness, personality changes, and signs of increasing stupor.
K. Instruct client and family in disease process and rationale for treatment.
L. Prevent and control complications: ascites, bleeding esophageal varices, hepatic encephalopathy, and anemia.
M. Provide postoperative care if peritoneovenous shunt is placed for intractable or circulatory failure.

Medications for Liver Disease

Medical–Surgical Nursing

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