The nurse has reviewed the nurses' notes Day 2 at 0800 and 1200 and vital signs and laboratory results Day 3 at 0800

Exhibits

The nurse is reviewing the client's electronic medical record. Click to highlight the findings that indicate an improvement of the client's condition. To deselect a finding, click on the finding again.

Day 3, 0800:

• Temperature 37° C (98.6° F)
• Blood pressure 112/56 mm Hg Heart rate 88/min
• Respiratory rate 20/min
• Oxygen saturation 95% on room air (95% to 100%)

Day 3, 0800:

• Haemoglobin 15 g/dL (14 to 18 g/dL)
• Haematocrit 45% (42% to 52%)
• Platelets 100,000/mm3 (150,000 to 400,000/mm3)
• Albumin 3.0 g/dL (3.5 to 5 g/dL)
• Ammonia 160 mcg/dL (10 to 80 mcg/dL)

Rationale:

A. "I understand that I need to inspect my feet daily."Daily foot inspection is essential for individuals with diabetes to identify any cuts, blisters, or signs of infection early. Reduced sensation due to peripheral neuropathy can lead to unnoticed injuries that progress to serious complications if untreated.
B. "I will dry my feet thoroughly when I get out of the shower." Keeping the feet dry, especially between the toes, helps prevent fungal infections and skin breakdown. Moist environments encourage fungal growth, which can worsen foot health in diabetic clients.
C. "It is important to apply lotion to my feet and especially my toes to keep my skin in good health." While moisturizing helps prevent dry, cracked skin, lotion should not be applied between the toes. Moisture trapped between the toes increases the risk of fungal infections and skin maceration in diabetic clients.
D. "I will be very careful when I cut my toenails and will be sure to cut them straight across and then file the edges with an emery board." Cutting toenails straight across and filing the edges helps prevent ingrown toenails and reduces the risk of accidental skin injury. Diabetic clients are advised to be cautious during nail care due to impaired healing and infection risk.
E. "I will wear closed toed shoes." Wearing closed-toed shoes protects the feet from injury and trauma. Open-toed shoes or sandals may expose the feet to injury, and diabetic clients may not feel injuries due to neuropathy.
F. "I am glad I can still go barefoot in the house because I never wear shoes at home."Going barefoot, even indoors, increases the risk of stepping on sharp objects and sustaining unnoticed injuries. Clients with diabetes should always wear well-fitting shoes or protective footwear, even at home.
G. "If I have any foot sores or corns come up, I will see my doctor or go to a podiatrist instead of treating it myself." Diabetic clients should avoid self-treating foot problems like sores or corns. Prompt evaluation by a healthcare provider prevents complications like infections or ulcers, which can escalate quickly in this population.

Rationale:

• Place on a Low-protein diet: A low-protein diet is often prescribed in clients with hepatic encephalopathy to reduce ammonia production from protein metabolism. With an ammonia level of 150 mcg/dL and signs of chronic liver disease, this is appropriate.
• Daily abdominal girth measurements: This client has a distended abdomen with dullness to percussion, suggesting ascites. Measuring abdominal girth daily helps monitor fluid accumulation and response to diuretics or fluid restriction.
• Daily weights: Weight tracking is essential in clients with ascites or fluid imbalance, common in cirrhosis. It provides a sensitive indicator of fluid retention or loss over time.
• Liver biopsy: With thrombocytopenia (platelets 120,000/mm³), active GI bleeding, and coagulopathy likely due to cirrhosis, liver biopsy poses a high bleeding risk and is not appropriate in this unstable condition.
• Administer lactulose: Lactulose is a first-line treatment for hepatic encephalopathy. It works by trapping ammonia in the colon and promoting its excretion. This is essential given the client's elevated ammonia level and risk for mental status changes.
• Liver ultrasound: A liver ultrasound is a non-invasive imaging tool to evaluate liver size, structure, and presence of masses or ascites. It is safe and appropriate in this client's condition and can guide further management.