Case Study Question 4
The nurse is caring for a 67-yr-old male client with a history of alcohol use disorder and cirrhosis admitted to the medical-surgical unit.
Nurses’ Notes
DAY 1 1000. Admitted with ascites and confusion; oriented to person only. Has a 25-yr history of alcohol use disorder, mild hypertension, and gastroesophageal reflux disease. Drowsy and dozing off and on, mildly dyspneic, appears thin and malnourished; somewhat agitated answering questions. States have not had a drink in a few weeks; sister who accompanied him notes recent drinking binge a week ago. Placed on oxygen 2 L per nasal cannula. Bulging flanks and peripheral edema noted. Bloodwork sent to lab. Admission weight 142 lbs (64.5 kg).
1400. Remains alert at times but confused, mumbling off and on; mild hand flap noted. Moderately dyspneic on 2 L nasal oxygen, RR 26. Bulging flanks and prominent veins around the umbilicus noted; provider notified.
Vital Signs
Time Day1: 1000 Day1: 1400
Temp 98.4F/36.9C 98.6F/37C
P 85 86
RR 22 26
B/P 142/72 145/78
Pulse oximeter 92% on 2L NC 89% on 2L NC
Glasgow Coma (3-15) 12 12
Abdominal girth 95 cm/37.5in
Medications
Medication Dosage/Frequency/ Route Time
metoprolol XL 50 mg daily 1000
Laboratory Report
Lab Results Reference range
BUN 22 mg/dL 10-20 mg/dL
Glucose (fasting) 70 mg/dL Normal < 99 mg/dL
Ammonia 94 mcg/dL 10-80 mcg/dL
Albumin 3.2 g/dL 3.4-5.4 g/dL
The client receives the diagnosis of hepatic encephalopathy.
For each potential intervention, click to specify whether the intervention is indicated, not indicated, contraindicated in the plan of care.
Potential Intervention Indicated Not Indicated Contraindicated
Neuro assessment every 4 hrs o o o
Record abdominal girth daily o o o
Administer acetaminophen 650 mg PRN for temp > 101 o o o
Monitor pulse oximetry every 4 hrs o o o
Administer sedative PRN agitation o o o
Daily weights o o o
Supine position when in bed o o o
Low sodium diet o o o
Point of care glucose every 6 hrs o o o
Lactulose 30 ml every 4 hrs X 3 doses o o o