Nursing Diagnosis for Cirrhosis :

Risk for Injury related to portal hypertension, changes in clotting mechanisms and disruption in the process of drug detoxification.

Goal : Reducing the risk of injury.

Nursing Interventions, Rational and Outcome criteria – Risk for Injury related to Cirrhosis:

1. Notice any feces excreted to check the color, consistency and amount.

Rational : Allows detection of bleeding in the gastrointestinal tract.

2. Be aware of the symptoms of anxiety, a feeling of fullness in the epigastrium, weakness and restlessness.

Rational : Can show early signs of bleeding and shock.

3. Check each stool and vomit to detect occult blood.

Rational : detecting early signs that prove the bleeding.

4. Observe hemorrhagic manifestations: ecchymosis, epistaxis, petechiae and bleeding gums.

Rational : Shows the changes in the blood clotting mechanism.

5. Record vital signs at regular intervals.

Rational : Provide the basis and evidence of hypovolemia and shock.

6. Keep the patient calm and restrict activity.

Rational : Minimizing the risk of bleeding and straining.

7. Observations conducted during blood transfusion.

Rational : Allows detection of transfusion reactions (risk will increase with the implementation of more than one transfusion is needed to address the active bleeding from esophageal varices).

8. Measure and record the nature, timing and amount of vomit.

Rational : Help evaluate the extent of bleeding and blood loss.

9. Keep the patient in a state of fasting if needed.

Rational : Reduce the risk of aspiration of gastric contents and minimize the risk of further injury to the esophagus and stomach.

10. Give vitamin K as prescribed.

Rational : Improve freezing by providing fat-soluble vitamins are necessary for blood clotting mechanism.

11. Accompany patients continuously for bleeding episodes.

Rational : Calming anxious patients and enable monitoring and detection of subsequent patient needs.

12. Offer a cold drink by mouth when bleeding is resolved (if instructed).

Rational : Reduce the risk of further bleeding by vasoconstriction of blood vessels increases the esophagus and stomach.

13. Take action to prevent injury:

a. Maintaining a safe environment.

Rational : Reducing the risk of trauma and bleeding to avoid injuries, falls, cuts, etc..

b. Encourage patient to blow his nose slowly.

Rational : Reduce the risk of epistaxis secondary to trauma and decrease blood clotting.

c. Provides a soft toothbrush and avoid using toothpicks.

Rational : Preventing trauma to the oral mucosa while good oral hygiene improved.

d. Encourage consumption of foods with a high vitamin C content.

Rational : Preventing trauma to the oral mucosa while good oral hygiene improved.

e. Perform a cold compress if necessary.

Rational : Reduce bleeding into the tissues by increasing local vasoconstriction.

f. Take note of the location where the bleeding.

Rational : Allows detection of new and bleeding where monitoring of previous bleeding.

g. Using a smaller needle when injecting.

Rational : Minimizing blood loss due to seepage and injecting many times.

14. Give drug with caution; monitor adverse drug delivery.

Rational : Reduce the risk of side effects that occur secondary to the inability of the damaged liver to detoxify (metabolize) the drug normally.

Outcome criteria :