Question

Scenario:

Jane Doe is approximately 50 years old and is admitted to your unit from the emergency department with the diagnosis of rule out hepatic encephalopathy with acute alcohol (ETOH) intoxications. This women was sent to the ED by local police, who found her lying unresponsive along a rural road.

Examination and x-ray studies are negative for any injury and you are awaiting the results of the blood alcohol level and toxicology tests. She has no identification and is not awake or coherent enough to answer questions or give any history.

The client is lethargic, has a cachectic appearance, does not follow commands consistently, and is mildly combative when aroused. She smells strongly of ETOH and has a notable distended stomach, and edematous lower extremities.

Jane Doe has a foley catheter in place and has IV of D5 ½ NS with 20 mEq KCL with 1 ampule of multivitamins infusing at 75 mL/hr.

What physical s/s suggest impaired liver function?

What lab results will you monitor? Which are a priority?

Since your patient has a history of alcohol abuse, poor nutritional intake, and impaired judgment, what are your nursing priorities?

Which of the following admitted orders will you question?

IV D5 ½ NS with 20 mEq to run at 75mL per hour; add 1 ampule of MVI to 1L of IV fluid daily.

NPO

Insert Salem sump nasogastric tube and attach to low continuous suction.

Foley catheter to gravity drainage.

Position patient supine in bed.

Lactulose (Cephulac) 45mL po QID until diarrhea.

Abdominal ultrasound in am.

Vitamin K (Aquamephyton) 10mg IV or po when alert and able to swallow.

Labs: CBC with differential, metabolic panel, liver function tests, PT/INR and PTT, serum ammonia now and in am.

When patient is more alert and able to swallow, may have high-protein diet.

For pain, give Norco or Vicodin one or two tablets every 4-6 hours prn.

Apply restraints if needed for combative behavior/irritability.

Call house officer for any signs of GI bleeding, delirium tremors, systolic B/P over 140 or less than 100 mm Hg; diastolic less than 50 mm Hg; or pulse over 120 beats per minute.

Answer 1

1.The physical sign and symptoms of impaired liver function include yellowish discolouration of the skin and eyes

Swelling over the lower limbs

Abdominal distension

2.Tha lab result need to monitor are Liver function test,CBC, complete urine examination,PT INR,Serum ammonia

3.Risk for self harm,injury and fall due to the alcohol withdrawal.

Impaired nutritional status due to poor intake

Risk for injury due to impaired judgement

4.Position the patient supine on the bed.Because keeping the patient supine on the bed avan increase the irritability due to discomfort.

The other orders are required for the patient care for the better outcome