Question

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action

will be included in the plan of care?
a. Restrict daily dietary protein intake.
b. Reposition the patient every 4 hours.
c. Perform passive range of motion twice daily.
d. Place the patient on a pressure-relief mattress.

Answer 1

In a patient with cirrhosis who has ascites and 4+ edema of the feet and legs, the nursing action that is typically included in the plan of care is:

**b. Reposition the patient every 4 hours.**

Repositioning the patient every 4 hours helps prevent the development of pressure ulcers, also known as bedsores. Patients with significant edema are at an increased risk of skin breakdown, especially over bony prominences. By changing the patient's position regularly, nurses can reduce the pressure on vulnerable areas of the skin and promote skin integrity.

While managing cirrhosis and associated complications, dietary modifications, passive range of motion exercises, and pressure-relief mattresses may also be part of the overall care plan, but addressing the risk of pressure ulcers through regular repositioning is a fundamental nursing intervention.