Case study - Cirrhosis: Nursing

Nurse Abigail works on a Medical-Surgical unit and is caring for Thomas, a 72-year-old male with a history of hyperlipidemia and obesity, who was recently admitted for cirrhosis secondary to nonalcoholic fatty liver disease. After settling Thomas in his room, Nurse Abigail goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Thomas’ care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.  

First, Nurse Abigail recognizes important cues, including Thomas’ vital signs, which are temperature 98.8 F or 37 C, heart rate 98 beats per minute, respirations 22 breaths per minute, blood pressure 106/68 mmHg, and oxygen saturation 97 percent on room air. His pain is 2 out of 10.  

Upon assessment, Nurse Abigail notes his sclera and skin are yellow-tinged, he has scattered petechiae, and his abdomen is round and distended.  

When asked to turn side-to-side during assessment, Thomas becomes fatigued and short of breath. 

Next, Nurse Abigail analyzes these cues. She reviews the electronic health record, or EHR, and notes that Thomas has gained 17 pounds since his last health care provider visit, which was approximately two weeks ago.  

Nurse Abigail recognizes that the fluid build-up in Thomas’ abdomen, also known as ascites, has contributed to his weight gain, and can make it difficult to perform physical activities because of increased pressure on his diaphragm, leading to dyspnea.  

She also knows that chronic illness in general can cause fatigue. Nurse Abigail realizes Thomas needs management of his fatigue in order to promote physical mobility. 

Now, using the information she's gathered, along with Thomas’ medical history, Nurse Abigail chooses a priority hypothesis of activity intolerance.  

Then, she generates solutions to address Thomas’ activity level that will include pharmacologic and nonpharmacologic interventions; and she establishes the expected outcome that after intervening, Thomas will tolerate sitting on the edge of the bed for five minutes. 

Nurse Abigail then takes action to implement these solutions.  

First, she calls the health care provider to report her assessment findings and receives orders for two diuretics, furosemide and spironolactone, as well as a physical therapy consult. As she waits for the pharmacist to approve the medication order, she speaks to Thomas about his plan of care.