Primary Nursing Diagnosis

Fluid volume excess related to retention

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

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


MEDICAL. Patients are placed on a well-balanced, high-calorie (2500 to 3000 calories per day), moderate- to high-protein (75 g of high-quality protein per day), low-fat, low-sodium diet (200 to 1000 mg per day), with additional vitamins and folic acid. Accurate fluid intake and output are important to prevent fluid volume overload; for most patients, intake should be limited to 500 to 1000 mL per day. Frequently, vitamin K injections are ordered to improve blood clotting factors. If coagulopathies worsen, treatment may require whole blood or fresh-frozen plasma to maintain the hematocrit and hemoglobin. If alcohol is the primary etiologic factor in liver cirrhosis, strongly encourage the patient to cease drinking.

SURGICAL. Surgical intervention includes a LaVeen continuous peritoneal jugular shunt (peri-toneovenous shunt), which may be inserted for intractable ascites. This procedure allows the continuous shunting of ascitic fluid from the abdominal cavity through a one-way valve into a silicone tube that empties into the superior vena cava. Paracentesis may be performed if conditions warrant. Indicators include a large volume of ascitic fluid that compromises the patient's respirations, causes abdominal discomfort, or poses a threat of rupturing an umbilical hernia.

Commonly seen in cirrhosis patients are esophageal varices due to portal vein hypertension. Varices can rupture as a result of anything that increases the abdominal venous pressure, such as coughing, sneezing, vomiting, or the Valsalva's maneuver. To remedy bleeding of esophageal varices, a Sengstaken-Blakemore tube can be placed. In cases of irreversible chronic liver disease, liver transplantation is an option; however, there are selection criteria. Candidates for liver transplantation fall into three categories: those with irreversible chronic liver disease; those with malignancies of the liver and biliary tree; and those with fulminant hepatic failure. Liver transplantation is considered an important therapeutic option for patients with end-stage liver disease, with 1-year and 5-year survival rates of 70% and 60%, respectively.

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