Medical Surgical Nursing

NURSING PROCESS:

THE PATIENT WITH HEPATIC CIRRHOSIS

Nursing diagnoses and goals

1. Activity intolerance related to fatigue, lethargy, and malaise

Goal: Patient reports decrease in fatigue and reports increased ability to

participate in activities

2. Imbalanced nutrition: less than body requirements, related to abdominal

distention and discomfort and anorexia

Goal: Positive nitrogen balance, no further loss of muscle mass; meets

nutritional requirements

3. Impaired skin integrity related to pruritus from jaundice and edema.

Goal: Decrease potential for pressure ulcer development; breaks in skin

integrity

4. High risk for injury related to altered clotting mechanisms and altered level of

consciousness

Goal: Reduced risk of injury

5. Disturbed body image related to changes in appearance, sexual dysfunction, and

role function

Goal: Patient verbalizes feelings consistent with improvement of body image

and self-esteem

6. Chronic pain and discomfort related to enlarged tender liver and ascites

Goal: Increased level of comfort

7. Fluid volume excess related to ascites and edema formation

Goal: Restoration of normal fluid volume

8. Disturbed thought processes related to deterioration of liver function and

increased serum ammonia level

Goal: Improved mental status; safety maintained

9. Risk for imbalanced body temperature: hyperthermia related to inflammatory

process of cirrhosis or hepatitis