Primary Nursing Diagnosis

Fluid volume excess related to water and sodium retention

OUTCOMES. Fluid balance; Hydration; Nutrition management; Nutrition therapy; Knowledge: Treatment regime

INTERVENTIONS. Fluid/electrolyte management; Fluid monitoring; Medication administration

U PLANNING AND IMPLEMENTATION Collaborative

Patients are managed with supportive therapy, depending on their symptoms. Fluid and electrolyte imbalances, malnutrition, ascites, respiratory failure, and bleeding esophageal varices can all occur with liver failure. Unless the patient has clinically significant hyponatremia, the patient usually receives limited IV fluids and food that contains sodium because increased sodium intake makes peripheral edema and ascites worse. Patients with ascites are usually restricted to 500 mg of sodium per day. A paracentesis may be used to remove 4 to 6 L of fluid. If the ascites is refractory, surgical placement of a peritoneal-venous shunt may be needed. Hypokalemia usually needs to be corrected with IV replacements. If the patient has serious fluid imbalances, a pulmonary artery catheter may be inserted for hemodynamic monitoring.

If respiratory failure is present, the patient may need endotracheal intubation and mechanical ventilation with supplemental oxygen. To manage nutrition in patients without evidence of hepatic encephalopathy, a high-calorie, 80- to 100-g protein diet is prescribed to allow for cellular repair. Some patients may need enteral or total parenteral nutrition to maintain calorie and protein levels. Hepatorenal failure is treated by fluid restriction, maintenance of fluid and electrolyte balance, and withdrawal of nephrotoxic drugs. Renal dialysis is generally not used because it does not improve survival and can lead to additional complications.

If the patient develops hepatic encephalopathy, serial neurological assessments are needed. In patients with signs of elevated intracranial pressure or hepatic coma, the physician may place an intracranial monitoring system. Some patients with liver failure are candidates for transplantation. A liver transplant is indicated for patients with irreversible progressive liver disease who have no alternatives to transplantation. Prior to liver transplantation for FHF, mortality generally was greater than 80%; about 5% of liver transplants in the United States are for FHF.

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