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!