NURSING DIAGNOSIS: Knowledge deficit or Altered health maintenance*

*The nurse should select the diagnostic label that is most appropriate for the client's discharge teaching needs.

Desired Outcome
The client will identify ways to prevent further liver damage.
Nursing Actions and Selected Purposes/Rationales
  1. Provide the following instructions regarding ways to prevent further liver damage:
    1. avoid the following hepatotoxic agents:
      1. alcohol
      2. cleaning agents containing carbon tetrachloride (these are toxic even when inhaled)
    2. take acetaminophen (e.g. Tylenol) only when necessary and do not exceed the recommended dose because of its potential toxic effect on the liver
    3. adhere to the following precautions to prevent hepatitis:
      1. eat only in restaurants that have been inspected and approved by health authorities
      2. if blood transfusions are anticipated, arrange to donate and receive autologous blood rather than commercially obtained blood if possible
      3. avoid sharing food or eating utensils and handling toiletry items of others
      4. practice safe sex (e.g. condom use for intercourse)
      5. avoid oral-anal sex since it is one of the ways that hepatitis A can be transmitted
      6. do not share drug paraphernalia (e.g. needles, straws for intranasal cocaine inhalation)
      7. get vaccinations for hepatitis A and B if recommended by health care provider
      8. if traveling to a developing country:
        1. receive immune globulin and vaccines for hepatitis (e.g. hepatitis B vaccine, hepatitis A vaccine) as recommended by health care provider
        2. drink only bottled water and avoid eating raw fruits and vegetables washed or prepared with local water when in the country.
Desired Outcome
The client will verbalize an understanding of the rationale for and components of the recommended diet.
Nursing Actions and Selected Purposes/Rationales
  1. Reinforce the dietary instructions outlined in Diagnosis 3, action c.2.
  2. Explain the rationale for a diet low in sodium and provide information about decreasing sodium intake:
    1. read food labels and calculate sodium content of items; avoid those products that tend to have a high sodium content (e.g. canned soups and vegetables, tomato juice, commercial baked goods, commercially prepared frozen or canned entrees and sauces)
    2. do not add salt when cooking foods or to prepared foods; use low-sodium herbs and spices if desired
    3. avoid cured and smoked foods
    4. avoid salty snack foods
    5. avoid commercially prepared fast foods
    6. avoid routine use of over-the-counter medications with a high sodium content (e.g. some antacids, Alka-Seltzer).
  3. Obtain a dietary consult to assist client in planning meals that will meet prescribed dietary modifications.
Desired Outcome
The client will identify ways to reduce stress on esophageal blood vessels.
Nursing Actions and Selected Purposes/Rationales
  1. Provide the following instructions about ways to reduce stress on esophageal blood vessels:
    1. adhere to prescribed measures to reduce fluid retention (e.g. fluid restriction, low-sodium diet, diuretics)
    2. avoid activities that increase intra-abdominal pressure (e.g. straining to have a bowel movement, coughing, sneezing, lifting heavy objects).
Desired Outcome
The client will identify ways to prevent bleeding.
Nursing Actions and Selected Purposes/Rationales
  1. Instruct client about ways to minimize risk of bleeding:
    1. avoid taking aspirin and other nonsteroidal anti-inflammatory agents (e.g. ibuprofen) on a regular basis
    2. use an electric rather than a straight-edge razor
    3. floss and brush teeth gently
    4. cut nails carefully
    5. avoid situations that could result in injury (e.g. contact sports)
    6. avoid blowing nose forcefully
    7. avoid straining to have a bowel movement
    8. avoid putting sharp objects (e.g. toothpicks) in mouth
    9. do not walk barefoot.
  2. Instruct client to control any bleeding by applying firm, prolonged pressure to the area if possible.
Desired Outcome
The client will identify ways to reduce the risk of infection.
Nursing Actions and Selected Purposes/Rationales
  1. Instruct client in ways to reduce risk of infection:
    1. continue with coughing and deep breathing or use of incentive spirometer every 2 hours while awake as long as activity is limited
    2. increase activity as tolerated
    3. avoid contact with persons who have an infection
    4. avoid crowds, especially during flu and cold seasons
    5. decrease or stop smoking
    6. drink at least 10 glasses of liquid/day unless on a fluid restriction
    7. adhere to recommended diet
    8. take supplemental vitamins and minerals as prescribed
    9. maintain good personal hygiene
    10. receive immunizations (e.g. influenza vaccine, pneumococcal vaccine, hepatitis vaccines) if approved by health care provider.
Desired Outcome
The client will identify ways to relieve pruritus.
Nursing Actions and Selected Purposes/Rationales
  1. Reinforce instructions in Diagnosis 4, action b, regarding ways to relieve itching.
  2. Instruct client to take bile acid sequestering agents (e.g. cholestyramine) or an antihistamine as prescribed.
Desired Outcome
The client will state signs and symptoms to report to the health care provider.
Nursing Actions and Selected Purposes/Rationales
  1. Stress the importance of reporting the following signs and symptoms:
    1. rapid weight gain or loss
    2. increasing size of abdomen
    3. increased swelling of lower extremities
    4. increasing shortness of breath
    5. increased itchiness or yellowing of skin
    6. temperature elevation that lasts more than 2 days
    7. red, rust-colored, or smoky urine; bloody or tarry stools; blood in sputum or vomitus; persistent bleeding from nose, mouth, or skin; prolonged or excessive menses; excessive bruising; severe or persistent headache; or sudden abdominal or back pain
    8. persistent impotence or decrease in libido
    9. tremors or changes in behavior, speech, or handwriting.
Desired Outcome
The client will identify community resources that can assist with home management and adjustment to lifestyle changes necessary for effective management of cirrhosis.
Nursing Actions and Selected Purposes/Rationales
  1. Provide information regarding community resources that can assist client and significant others with home management and adjustment to changes necessary for effective management of cirrhosis (e.g. Meals on Wheels, home health agencies, transportation services, drug and alcohol rehabilitation programs, counseling services).
  2. Initiate a referral if indicated.
Desired Outcome
The client will verbalize an understanding of and a plan for adhering to recommended follow-up care including future appointments with health care provider, medications prescribed, and activity level.
Nursing Actions and Selected Purposes/Rationales
  1. Reinforce the importance of keeping follow-up appointments with health care provider.
  2. Explain the rationale for, side effects of, and importance of taking medications prescribed. Inform client of pertinent food and drug interactions.
  3. Reinforce physician's instructions regarding activity level. Stress the importance of rest.
  4. Implement measures outlined in Diagnosis 13, action b, to promote the client's ability to effectively manage the therapeutic regimen.