Question

A client is being treated for hepatic failure. On examination, the client has a weight gain of 4.4 lbs (2kg) in 24 hours and an elevated pulse rate. Which intervention should the nurse include in the plan of care?

a. Review arterial blood gases results.
b. Assess for dependent pitting edema.
c. Document abdominal girth.
d. Record usual eating patterns.

Answer 1

The most appropriate nursing intervention for a client with hepatic failure experiencing weight gain and elevated pulse is to assess for dependent pitting edema (option b), which is indicative of fluid retention related to liver dysfunction.

Step-by-step explanation:

In the case of a client being treated for hepatic failure who has exhibited a significant weight gain of 4.4 lbs in 24 hours and an elevated pulse rate, a pertinent nursing intervention would be to assess for dependent pitting edema. This specific symptom is commonly associated with fluid accumulation, which can occur due to impaired liver function and fluid management in conditions such as cirrhosis, leading to ascites. Documenting abdominal girth may also be relevant since it can be indicative of fluid retention in the abdominal cavity.

Reviewing arterial blood gases may be necessary if there is concern for respiratory or metabolic disturbances, particularly if the patient is showing signs of hepatic encephalopathy, which can occur with liver failure. Insight into usual eating patterns might be relevant for nutritional assessment but is less directly connected to the acute symptoms of weight gain and elevated pulse.