Hepatic encephalopathy secondary to liver cirrhosis

Client is in their 60s, male, with hepatic encephalopathy secondary to liver cirrhosis. Data Cluster Actual Problem Data Cluster 1: Client presents history of excessive alcohol intake, diabetes mellitus, decompensated hepatic cirrhosis

Actual Client Problem 1: Impaired for liver function

Data Cluster 2: Client presents anasarca, ascites, edema during skin assessment, decrease in hematocrit( 28.3) (decrease in hemoglobin (9.4), alteration in mental status (neuro assessment indicated alert and oriented times 2 but confused with time and situation and hard of hearing), alteration in respiratory pattern (respiratory assessment indicated lung sounds diminished at bilateral bases)

Actual Client Problem 2: Fluid Volume Excess related to retention

Of the 2 problems identified above, determine the higher-priority problem. Restate the actual problem with supporting client data and provide evidence for why you determined which diagnosis is higher priority.

For the High Priority Client Problem, develop two expected outcomes for the client.  For each outcome, develop 2 related nursing interventions; interventions should be appropriate for and individualized to the client.  For each intervention, include rationale (why the intervention is appropriate) and an in-text citation supporting that it is evidence-based.  Interventions may include assessment/monitoring, education and collaboration with Interprofessional team members.

Outcomes should be specific and address only 1 parameter.
Outcomes should be measureable and relate to an observable change.
Outcomes should be achievable and agreed-upon with the client.
Outcomes should be realistic based on the client’s abilities, preferences and resources.
Outcomes should be time-limited (generally within the shift so the nurse can evaluate).

Provide narrative documentation of 1 selected nursing intervention (above) in D-A-R format.

Re-state above outcome criteria and provide evidence that the outcome was met or not met.