A client with alcohol-related cirrhosis is admitted with grade 2 hepatic encephalopathy and ascites. Which nursing actions are appropriate? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
Lactulose is first-line therapy for overt hepatic encephalopathy and is titrated to improved cognition and about 2 to 3 soft bowel movements daily; excessive diarrhea can cause hypovolemia and worsen encephalopathy (Choice 2). Fever, abdominal pain, hypotension, kidney injury, or worsening mental status may indicate spontaneous bacterial peritonitis and require prompt diagnostic paracentesis and treatment (Choice 3). Sodium restriction and daily weights help assess ascites and the response to diuretics (Choice 5). NSAIDs can worsen renal perfusion, fluid retention, and bleeding risk in decompensated cirrhosis (Choice 1). Elevating the head of the bed generally supports ventilation when ascites limits diaphragmatic excursion (Choice 4). Routine severe protein restriction worsens malnutrition and sarcopenia; guidance generally targets 1.2 to 1.5 g/kg/day of protein rather than chronic restriction (Choice 6). Hepatic encephalopathy is assessed clinically; an ammonia value alone does not grade severity or guide lactulose dosing.
Clinical Judgment Cirrhosis care is bundled around portal hypertension complications: ammonia control + sodium-restricted ascites care + bleeding precautions + infection surveillance. The nurse links bedside actions to the underlying physiology — gut bacteria produce ammonia, sodium drives ascites, and inflammation in the peritoneum signals SBP.
Memory Tip Cirrhosis red flags = A-V-A-N-T: Ascites · Varices · Ammonia (encephalopathy) · NSAIDs forbidden · Think SBP with fever and pain.
KR vs US Korean wards historically restricted protein in cirrhosis; current evidence and NCLEX-RN reflect adequate protein 1.2 to 1.5 g/kg/day. The Korean diet is also relatively high in sodium — explicit teaching on the 2 g/day limit is essential at discharge.
Clinical Practice GuideAASLD and EASL cirrhosis guidelines: lactulose first line for hepatic encephalopathy, rifaximin added for recurrent episodes, spironolactone first line for ascites with furosemide added in a 100:40 ratio, and non-selective beta-blockers for variceal prophylaxis. Diagnostic paracentesis at admission for any cirrhotic client with new ascites or worsening status — PMN > 250/microL diagnoses SBP. Avoid NSAIDs and aminoglycosides.
CautionCommon NCLEX traps: severe protein restriction, NSAIDs for pain, lying flat after meals, and skipping ascitic fluid analysis when SBP signs appear. Remember: cirrhosis is a bleeding and infection-risk state — protect both.
Hepatic Encephalopathy — Reversible neuropsychiatric syndrome in cirrhosis driven by accumulation of gut-derived neurotoxins, primarily ammonia. Stages range from minimal cognitive change (covert) to coma. Asterixis is a classic sign. Treatment: lactulose titrated to 2 to 3 soft stools daily, rifaximin for recurrent episodes, treat precipitants (infection, GI bleed, electrolyte disturbance, sedatives). NCLEX exam tip: do not severely restrict protein — adequate protein supports nitrogen balance and reduces sarcopenia.
Ascites Management — Fluid accumulation in the peritoneal cavity in cirrhosis driven by portal hypertension and sodium retention. Management: dietary sodium less than 2 g/day, fluid restriction if serum sodium below 125, spironolactone first-line diuretic with furosemide added in a 100:40 ratio, daily weights. Tense or refractory ascites: large-volume paracentesis with albumin replacement (6–8 g per liter removed when more than 5 L). NCLEX exam tip: avoid NSAIDs because they reduce diuretic response and worsen renal function.
Spontaneous Bacterial Peritonitis (SBP) — Infection of ascitic fluid without an obvious intra-abdominal source. Triggers: gut translocation of bacteria. Diagnosis: ascitic fluid PMN count greater than 250/microL on diagnostic paracentesis. Triad of fever, abdominal pain, and worsening hepatic encephalopathy is classic but absence of pain is common in older adults. Treatment: third-generation cephalosporin (ceftriaxone or cefotaxime) plus albumin to prevent hepatorenal syndrome. NCLEX exam tip: any cirrhotic client with new fever or worsening encephalopathy needs SBP rule-out.