Question

THE PATIENT E NCEPHALOPATHY 131 2-3 THE PATIENT WITH WEDATIC ENCEPHALOPAIR 9700 Handoff Report: C ENCEPHALOPATHY Mr. U. 47 years old, is admitted with the di s hes ancephalopathy vanced cirrhosis of the Th This is his most of the restless, and confused to time and cle S T FAP 8 R2 pulse ox 92%. Unable to assessman de to keep him como A A pain level but every cortas patient care assistant was in his was in his room most of the M iss des this Patic encephalopathy related to his ad 100 were T 97"F Ax P 88, R 22BP 120/88 llowing patient care plan information is available 2 Priority Setting and Decision Making I&O ) VS q1h Neurocks qih Serum ammonia. K today Code status: No code DSW @ 100 mL/hr 320 g RFA-inserted today Bed rest with BRP Weigh daily Diet: TCHO. 50 g Prot., 2 g Na Routine med: Neomycin lspo qoh Lactulose 30 ml. po bid Prioritize the following five recommended urine intentions I Write a number in the box to identify the order of your intervi tion, etc.). and state a rationale for each intervention w s ill do them to take care of first intervention, 72 sec INTERVENTIONS PRIORITY Rationale • Take VS • Assess level of consciousness and orientation DDDD . Check current serum ammonia and Klevels • Perform a body systems physical assessment • Assist Mr. U with his activities of daily living and provide comfort care KEY POINTS TO CONSIDER myright © 2018, Elsevier Inc. All rights reserved.

Answer 1

Answer

Intervention	priority	Rationale
Take VS	2	changes in the Vital signs may indicate risk for bleeding due Impaired thrombopoietin production and risk for infection caused by tissue catabolism. To check compromised respiratory function.
Assess the level of consciousness and orientation	1	To assess the level of response and to determine the stage of disease. Untreated confusion can leads to coma.
Check the serum ammonia and k+ levels	3	To assess the risk of acidosis and hypokalemia.
Perform a body system physical assessment	4	To Monitor the patient for any signs of injury,bleeding ,edema, vomiting, urine output etc.
Assist Mr.U with his activities of daily living and comfort care.	5	Assisting Mr. U in ADL helps to conserve the energy. Because patients with hepatic failure will become fatigued easily.