Registered Nurse

ammonia levels. • Watch for asterixis, a sign of developing hepatic encephalopathy. • Monitor ammonia levels and assess neurologic status to determine the effectiveness of lactulose therapy. • Weigh the client and measure his abdominal girth daily, inspect the ankles and sacrum for dependent edema, and accurately record intake and output to assess fluid retention. • Carefully evaluate the client before, during, and after paracentesis because this drastic loss of fluid may induce shock. • Avoid using soap when bathing the client; instead, use lubricating lotion or moisturizing agents to prevent skin breakdown associated with edema and pruritus. • Handle the client gently, and turn and reposition him often to keep skin intact. • Encourage rest and good nutrition to help the client conserve energy and decrease metabolic demands on the liver. • Encourage frequent, small meals to ensure that nutritional needs are met. Teaching topics • Explanation of the disorder and treatment plan • Medication use and possible adverse effects • Importance of avoiding infections and abstaining from alcohol • Contacting Alcoholics Anonymous • Avoiding activities that increase intra abdominal pressure, such as heavy lifting, vigorous coughing, and straining during a bowel movement • Avoiding alcohol • Avoiding over-the-counter medications that may affect the liver such as acetaminophen.

Cirrhosis Cirrhosis is a chronic hepatic disease characterized by diffuse destruction of hepatic cells, which are replaced by fibrous cells. Necrotic tissue leads to fibrosis. Cirrhosis alters liver structure and normal vasculature, impairs blood and lymph flow, and eventually causes hepatic insufficiency. Cirrhosis is irreversible. CAUSES • Alcoholism and resulting malnutrition • Autoimmune disease, such as sarcoidosis, or chronic inflammatory bowel disease • Exposure to hepatitis (types A, B, C, and D; viral hepatitis) or toxic substances ASSESSMENT FINDINGS • Abdominal pain (possibly because of an enlarged liver) • Anorexia • Constipation • Diarrhea • Fatigue • Jaundice • Indigestion • Muscle cramps • Nausea • Vomiting • Weakness DIAGNOSTIC TEST RESULTS • Liver biopsy, the definitive test for cirrhosis, detects hepatic tissue destruction and fibrosis. • Liver enzyme levels are elevated. • CT scan with I.V. contrast medium reveals enlarged liver, identifies liver masses, and visualizes hepatic blood flow and obstruction, if present. • Magnetic resonance imaging can further assess hepatic nodules. Esophagogastroduodenoscopy reveals bleeding esophageal varices, stomach irritation or ulceration, or duodenal bleeding and irritation. • Blood studies reveal decreased platelets and decreased levels of Hb and HCT, albumin, serum electrolytes (sodium, potassium, chloride, magnesium), and folate. • Blood studies reveal elevated levels of globulin, ammonia, total bilirubin, alkaline phosphatase, AST, ALT, and LD and increased thymol turbidity, and glutamyltransferase. • Urine studies show increased levels of bilirubin and urobilinogen. • Stool studies reveal decreasing urobilinogen levels. NURSING DIAGNOSES • Imbalanced nutrition: Less than body requirements • Risk for injury • Ineffective breathing pattern TREATMENT • Blood transfusions • Fluid restriction (usually to 1,500 ml/day) • Schlerotherapy or gastric intubation and esophageal balloon tamponade for bleeding esophageal varices (Sengstaken-Blakemor method, esophago gastric tube method, Minnesota tube method) • I.V. therapy using colloid volume expanders or crystalloids • Oxygen therapy (may require endotracheal (ET) intubation and mechanical ventilation) • Paracentesis to reduce abdominal pressure from ascites • Transjugular intrahepatic portal-systemic shunting (TIPS procedure) as a last resort for clients with bleeding esophageal varices and portal hypertension • Sodium restriction (usually up to 500 mg/day) • Low-protein diet • Surgical intervention: peritoneovenous shunt Drug therapy • Antiemetic: ondansetron (Zofran) • Vasoconstrictor: vasopressin for esophageal varices • Diuretics: furosemide (Lasix), spironolactone (Aldactone) for edema (diuretics require careful monitoring; fluid and electrolyte imbalance may precipitate hepatic encephalopathy) • Vitamin K: phytonadione for bleeding tendencies caused by hypo prothrombinemia • Beta-adrenergic blocker: propranolol (Inderal) to decrease pressure from varices • Laxative: lactulose to reduce serum ammonia levels INTERVENTIONS AND RATIONALES • Assess respiratory status frequently because abdominal distention may interfere with lung expansion. Position the client to facilitate breathing. • Check skin, gums, stools, and emesis regularly for bleeding to recognize early signs of bleeding and prevent hemorrhage. • Apply pressure to injection sites to prevent bleeding. • Warn the client against taking aspirin, straining during defecation, and blowing his nose or sneezing too vigorously to avoid bleeding. Suggest using an electric razor and a soft toothbrush. These measures also prevent bleeding. • Observe the client closely for signs of behavioral or personality changes—especially increased stupor, lethargy, hallucinations, and neuromuscular dysfunction. Behavioral or personality changes may indicate increased

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Emergence of acute coronary syndromes

Teaching tips for MS Teaching the client how to live with multiple sclerosis (MS) is important in managing his care. Begin by teaching the client and his family about the chronic course of MS. Emphasize the need to avoid stress, infections, and fatigue and to maintain independence by developing new ways of performing daily activities. FAMILY FUNCTION • Teach the family to assist with physical therapy, such as active, resistive, and stretching exercises to maintain muscle tone and joint mobility, decrease spasticity, and improve coordination. • Tell them that massages and relaxing baths can increase the client’s comfort. • Explain that bath water shouldn’t be too hot because it may temporarily intensify otherwise subtle symptoms. • Encourage the family and client to establish a daily routine to maintain optimal functioning. Activity should be regulated by the client’s tolerance. The client should be encouraged to have regular rest periods to prevent fatigue.

Multiple sclerosis Multiple sclerosis is a neurodegenerative disease caused by degeneration of the myelin sheath in neurons of the brain and spinalcord. It results in patches of sclerotic tissue that impair the ability of the nervous system to conduct motor nerve impulses. CAUSES • Autoimmune response • Environmental or genetic factors • Slow-acting or latent viral infection • Unknown ASSESSMENT FINDINGS • Ataxia • Feelings of euphoria • Heat intolerance • Inability to sense or gauge body position • Intention tremor • Nystagmus, diplopia, blurred vision, optic neuritis • Scanning speech • Urinary incontinence or retention • Weakness, paresthesia, impaired sensation, paralysis DIAGNOSTIC TEST RESULTS • CSF analysis shows increased immunoglobulin G, protein, and WBCs or it may be normal. • CT scan eliminates other diagnoses such as brain or spinal cord tumors. • MRI of the brain and spine shows scarring or lesions. NURSING DIAGNOSES • Ineffective airway clearance • Impaired physical mobility • Imbalanced nutrition: Less than body requirements • Risk for injury • Anxiety TREATMENT • A high-calorie, high-vitamin, gluten-free, and low-fat diet • Increased intake of fluids • Physical therapy • Plasmapheresis (for antibody removal) • Speech therapy Drug therapy • Cholinergic: bethanechol (Urecholine) • Glucocorticoids: prednisone, dexamethasone, corticotropin (ACTH) • Immunosuppressants: interferon beta-1b (Betaseron), cyclophosphamide (Cytoxan), methotrexate (Trexall) • Skeletal muscle relaxants: dantrolene (Dantrium), baclofen (Lioresal) INTERVENTIONS AND RATIONALES • Assess changes in motor coordination, paralysis, or muscular weakness and report changes to facilitate early intervention. • Assess respiratory status at least every 4 hours to detect early signs of compromise. • Maintain the client’s diet to decrease the risk of constipation. • Encourage fluid intake to decrease the risk of urinary tract infection. • Administer medications, as prescribed, to improve or maintain the client’s condition and functional status. • Encourage verbalization of feelings about changes in body image and provide emotional support to promote acceptance of muscular impairment. • Maintain active and passive exercises to maintain ROM and prevent musculoskeletal degeneration. • Establish a bowel and bladder program to decrease the risk of constipation and urinary retention. • Maintain activity, as tolerated (alternating rest and activity), to improve muscle tone and enhance self-esteem.