Anytime I care for a patient with cirrhosis of the
liver who is in crisis, my internal alarms go off. These patients often arrive
with high ammonia levels causing confusion, extreme malnutrition, coagulation
issues, and huge abdomens from ascites. Although we check their ammonia, coags
and mental status, they are not the most important aspects of our assessment.
When caring for a patient with the above issues,
what is the most important aspect of your nursing assessment?
If you answered “their respiratory rate” you are
correct!!!
Respiratory rate?? Why?
Our entire blood supply finds its way to the liver.
If the liver is cirrhotic (stiff), then the blood can’t get through easily –
therefore the blood backs up. When the blood backs up, it increases the
pressure in the portal system leading to fluid leaking into the abdominal
space (protein leaks contribute too). As a result, ascites occurs.
When this process exaggerates as in crisis, the
ascites can get so bad that it compresses the pulmonary system leading to
respiratory compromise. Basically, these patients can’t breath because their
lungs are getting squished. It’s their big bellies that put me on guard more
than any other sign!
I was caring for a patient with cirrhoses the other
day and kept vigilant over his respiratory status. Although he was only tachypneic
intermittently, I was worried about him. His belly was huge! As I gave report
to a newer nurse I made sure she understood about his belly and to keep an eye
on his respiratory status. I didn’t want her to miss the most important aspect
of her assessment on this patient!
Okay, let’s say your patient gets really tachypneic
and starts dropping his sats. What would be your intervention?
The first thing I do is to keep their head of bed
elevated. This can pull the fluid away from the lungs – good old-fashioned
gravity. However, if the patient is still tachypneic even with the HOB at 90
degrees, it’s time to call the physician. Then, you should anticipate a
paracentesis.
Now…warning..warning…warning! Some physicians may
want to remove a ton of fluid. However, if the patient’s had ascites for a long
time, his body is used to it. If you remove all of the fluid, the body will
react by shifting fluid from other spaces right back into the abdomen.
How much fluid should you expect the physician to
remove? Just enough fluid to bring down his respiratory rate to within normal
range. Remember, it’s all about reducing lung compression – not fixing the
ascites.
Okay. I hope this tip helps you successfully care
for patients with liver disease!
Thanks so much for reading and for choosing to
become a nurse! I’m cheering for your success!
Renee
For more great tips, make sure you "like" me on Facebook,"follow" me on Twitter and YouTube and subscribe to my blog. Also, check out my book on nurse-to-nurse bullying and my eBook titled, Survive and Thrive: A guide helping new nurses succeed!
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