- Acute Confusion related to Hepatic encephalopathy (HE) and accumulation of ammonia in the blood as evidenced by Confusion and Slurred speech
- Dysfunctional Family Processes Alcoholism related to Heavy alcohol use as evidenced by Physical effects of long-term alcohol use on the liver
- Ineffective Breathing Pattern Related to Increased intra-abdominal pressure and Hepatopulmonary syndrome as evidenced by Dyspnoea and Hyperventilation
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Hallucinations Paranoia Objective data: -Fluctuation in cognition/consciousness -Agitation/restlessness -Inappropriate perceptions -Lack of understanding or follow-through with tasks -Tremors | Acute Confusion related to Hepatic encephalopathy (HE) and accumulation of ammonia in the blood as evidenced by Confusion and Slurred speech | Patient will remain alert and oriented to person, place, and time Patient will initiate lifestyle behaviors to prevent recurrence (abstaining from alcohol use) | 1. Administer lactulose. Lactulose is a laxative that rids the body of ammonia and toxins through frequent bowel movements. 2. Prevent falls and injury. Due to the cognitive effects of HE, patients are at risk for falls and other injuries. Ensure the bed alarm is on at all times and the patient is supervised and assisted with ambulating and other ADLs. 3. Reorient as needed. Provide reorientation to person, place, time, and situation frequently to reduce confusion and maintain a sense of reality. 4. Educate on lifestyle changes. Managing cirrhosis can prevent HE. Patients should be advised to avoid alcohol, take prescribed medications to treat their liver disease, and maintain a healthy diet. 5. Decrease stimuli. Prevent increasing confusion and agitation by providing a calm, quiet environment and promoting relaxation. | Patient remained alert and oriented to person, place, and time Patient initiated lifestyle behaviors to prevent recurrence (abstaining from alcohol use) |
| Subjective data: Verbalizes the long term effect of Alcohol use Objective data: -Portal hypertension -Ascites -Jaundice -Splenomegaly -Poor nutrition | Dysfunctional Family Processes Alcoholism related to Heavy alcohol use as evidenced by Physical effects of long-term alcohol use on the liver | Patient will verbalize an understanding of the long-term effects of alcohol use on the liver Patient will agree to rehabilitation or Alcoholics Anonymous for support with addiction Patient will verbalize the consequences of alcohol use and identify necessary steps for change | 1. Reduce alcohol cravings. Medications are available to assist with alcohol addiction. Disulfiram is FDA-approved to treat alcoholism. Topiramate is effective in decreasing cravings and withdrawal symptoms. Baclofen is effective in promoting alcohol abstinence in patients with cirrhosis. 2. Refer to rehabilitation or AA. Addressing the underlying addiction is necessary to manage the disease. Patients should be provided resources for addiction counselling, Alcoholics Anonymous, as well as inpatient or outpatient rehab programs. 3. Coordinate with a dietician. Cirrhosis and alcoholism result in malnutrition. Patients are often deficient in folate, vitamin B6, vitamin A, thiamine, and zinc. Treating malnutrition depends on the severity of the disease and can be difficult. Assessment and treatment by a dietician may be necessary. 4. Prepare for liver transplantation. Cirrhosis cannot be cured and a liver transplant is the only treatment for end-stage liver disease. To qualify for a liver transplant, the patient must be committed to abstaining from alcohol. | Patient verbalized understanding of the long-term effects of alcohol use on the liver Patient agreed to rehabilitation or Alcoholics Anonymous for support with addiction Patient verbalized the consequences of alcohol use and identify necessary steps for change |
| Subjective data: -Difficulty breathing; shortness of breath or dyspnea -Anxiety in relation to breathing Objective data: -Dyspnea -Abnormal respiratory rate; tachypnea or bradypnea -Poor oxygen saturation -Abnormal ABG results -Shallow breathing -Pursed-lip breathing -Accessory muscle use when breathing -Nasal flaring -Cough | Ineffective Breathing Pattern Related to Increased intra-abdominal pressure and Hepatopulmonary syndrome as evidenced by Dyspnoea and Hyperventilation | Patient will demonstrate a normal breathing pattern without respiratory distress. Patient will report the ability to breathe comfortably while sitting or lying flat. | 1. Position the patient for comfort. Patients may experience dyspnea on exertion or when lying flat due to ascites, splenomegaly, or hepatomegaly. Allow the patient to remain upright to facilitate breathing. 2. Encourage the use of pillows for support. Promoting comfort using supportive pillows under the arms and chest can help patients with liver cirrhosis breathe comfortably. 3. Evaluate and monitor ABGs and oxygen saturation. Any alterations in ABG and oxygen saturation values can signal respiratory complications and enable prompt interventions. 4. Provide supplemental oxygen as indicated. Supplemental oxygen via nasal cannula can help treat hypoxia due to ineffective breathing patterns. This will also promote adequate oxygenation to the liver and reduce symptoms of dyspnea. 5. Prepare the patient for surgical interventions. Surgical interventions like abdominal paracentesis can help relieve abdominal pressure associated with liver cirrhosis and fluid accumulation, enabling the patient to breathe comfortably. | Patient demonstrated a normal breathing pattern without respiratory distress. Patient reported ability to breathe comfortably while sitting or lying flat. |