Medical Surgical Nursing

6. Prepare patient and assist

with paracentesis.

and cooperation with it

6. Paracentesis will temporarily

decrease amount of ascites

present.

sodium and fluid restriction

 Shows a decrease in ascites

with decreased weight



Nursing Diagnosis: Disturbed thought processes related to deterioration of liver function and increased serum

ammonia level

Goal: Improved mental status; safety maintained

1. Restrict dietary protein as

prescribed.

2. Give frequent, small

feedings of carbohydrates.

3. Protect from infection.

4. Keep environment warm and

draft-free.

5. Pad the side rails of the bed.

6. Limit visitors.

7. Provide careful nursing

surveillance to ensure

patient's safety.

8. Avoid opioids and

barbiturates.

9. Awaken at intervals (every

2 – 4 h) to assess cognitive

status.

1. Reduces source of ammonia

(protein foods)

2. Promotes consumption of

adequate carbohydrates for

energy requirements and

spares protein from

breakdown for energy

3. Minimizes risk for further

increase in metabolic

requirements

4. Minimizes shivering, which

would increase metabolic

requirements

5. Provides protection for the

patient should hepatic coma

and seizure activity occur

6. Minimizes patient's activity

and metabolic requirements

7. Provides close monitoring of

new symptoms and

minimizes trauma to the

confused patient

8. Prevents masking of

symptoms of hepatic coma

and prevents drug overdose

secondary to reduced ability

of the damaged liver to

metabolize opioids and

barbiturates

 Adheres to protein

restriction

 Demonstrates an interest

in events and activities in

environment

 Demonstrates normal

attention span

 Follows and participates

in conversation

appropriately

 Is oriented to person,

place, and time

 Remains in bed when

indicated

 Reports no urinary or fecal

incontinence

 Experiences no seizures