Risk for Deficient Fluid Volume/Bleeding | Nursing Care Plan for Hepatitis

Nursing diagnosis: risk for deficient Fluid Volume/Bleeding

Risk factors may include
Excessive losses through vomiting and diarrhea, third-space shift
Altered clotting process

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Hydration
Maintain adequate hydration, as evidenced by stable vital signs, good skin turgor, capillary refill, strong peripheral pulses, and individually appropriate urinary output.
Coagulation Status
Be free of signs of hemorrhage with clotting times WNL.

Nursing intervention with rationale:
1. Monitor intake and output (I&O) and compare with periodic weight. Note enteric losses, such as vomiting and diarrhea.
Rationale: Provides information about replacement needs and effects of therapy. Note: Diarrhea may be due to transient flulike response to viral infection or may represent a more serious problem of obstructed portal blood flow with vascular congestion in the gastrointestinal (GI) tract. Or, it may be the intended result of medication use, such as neomycin or lactulose, to decrease serum ammonia levels in the presence of hepatic encephalopathy.

2. Assess vital signs, peripheral pulses, capillary refill, skin turgor, and mucous membranes.
Rationale: Indicators of circulating volume and perfusion.

3. Check for ascites for edema formation. Measure abdominal girth, as indicated.
Rationale: Useful in monitoring progression and resolution of fluid shifts associated with edema and ascites.

4. Use small-gauge needles for injections, applying pressure for longer than usual after venipuncture.
Rationale: Reduces possibility of bleeding into tissues.

5. Have client use cotton or sponge swabs and alcohol-free mouthwash instead of toothbrush.
Rationale: Avoids trauma and bleeding of the gums. Note: Alcohol-based mouthwash may be irritating to dry mucosa.

6. Observe for signs of bleeding—hematuria and melena, ecchymosis, and oozing from gums or puncture sites.
Rationale: Prothrombin levels are reduced and coagulation times prolonged when vitamin K absorption is altered in GI tract, and synthesis of prothrombin is decreased in affected liver.

7. Monitor periodic laboratory values, such as Hgb/Hct, sodium, albumin, and clotting times.
Rationale: Reflects hydration status and identifies sodium retention and protein deficits, which may lead to edema formation. Deficits in clotting potentiate risk of bleeding.

8. Administer antidiarrheal agents, such as diphenoxylate with atropine (Lomotil).
Rationale: Reduces fluid and electrolyte loss from GI tract.

9. Provide intravenous (IV) fluids (usually glucose) and electrolytes
Rationale: Provides fluid and electrolyte replacement in acute toxic state.

10. Administer medications, as indicated, for example: Vitamin K
Rationale: Because absorption is altered, supplementation may prevent coagulation problems, which may occur if clotting factors are decreased.