Complex Issue & Patient Safety

Concept Map Assignment Part A & B

Talha Zafar
Humber College
Complex Issue & Patient Safety

Male patient with a history of: cirrhosis of the liver, ETOH x 25 years, and hypertension (blood pressure 162/74). Patient complained of
ascites,Issue
with mild&
shortness
of breath
on exertion (O2Sat 92%, respiratory rate 26). The patient has generalized edema. Pulse
Complex
Patient
Safety
2 is
tachycardic at 122. Pedal pulses are palpable. Patient is jaundiced throughout. Temperature is 37.5 C.
Increased respiratory rate r/t
ascites

Inefficient clearance of
CO2

At risk for
respiratory
acidosis

- Monitor respiratory
rate, depth, and effort.
Remain alert for critical
changes in patients
respiratory, CNS and
cardiovascular
functions.
Rationale:Patients with
respiratory acidosis will
present with abnormal
findings.
-Encourage and assist
with deep-breathing
exercises, turning, and
coughing. Suction as
necessary. Provide
airway adjunct as
indicated. Place in
semi-Fowlers position.
Rationale: These
measures improve lung
ventilation.
- Treat patient for acidbase disorder (based on
doctor orders).
Rationale: Treatment
of disorder is directed at
improving alveolar
ventilation. Addressing
the primary condition
(pulmonary edema)
promotes correction of
the acid-base disorder.
- Pt. Teaching r/t
respiratory acidosis
(cause, interventions
and self-care activities).
Rationale: Promotes
participation in
therapeutic regimen,
and may reduce
complication of
disorder.
-Monitor lab values and
assess patients risk of
developing respiratory
acidosis.
Rationale: A high
CO2and acidic pH
means the patient is
experiencing respiratory
acidosis.

Shortness of
breath (O2Sat
92%,
respiratory rate
- Oxygen therapy should
be initiated if the patient
is in distress or O2sats are
below a therapeutic range
(<89%) or as per orders.
Rationale: Oxygen
saturations <89% may
cause cyanosis, increase
workload of the heart,
and cause cardiac arrest.
- Pt. teaching r/t to
coloration between
disease process and SOB.
Rationale: SOB is
caused by fluid
accumulating in the
abdominal cavity. When
fluid accumulates in the
chest, it is called hepatic
hydrothorax (with liver
cirrhosis); which causes
SOB on exertion. The
patient needs to be
instructed to decrease
consumption of alcohol
because hepatic
hydrothorax is caused by
cirrhosis of the liver.
Cirrhosis of the liver is
caused by excess alcohol.
- Critically question
medication before
administering.
Rationale: E.G.: NSAID
drugs, which are
metabolized in the liver
may causes cirrhosis of
the liver fluid buildup
(increasing SOB).
- Administer diuretics as
per orders.
Rationale:Oral diuretics
cause the kidneys to
perfuse more and excrete
fluid.
- Encourage and assist
with deep-breathing
exercises, turning, and
coughing. Suction as
necessary. Provide
airway adjunct as
indicated. Place in semiFowlers position.
Rationale: These
measures improve lung
ventilation.

At risk for
pulmonary
edema

Instruct client to
follow a healthy diet
that is low in salt and
fat, and controlling
your other risk factors
can reduce the risk of
developing pulmonary
edema.
Rationale:Salt and fat
are risk factors for
hypertension and
cardiovascular disease
which can cause
pulmonary edema.
- Assess for signs and
symptoms of impaired
respiratory function:
dyspnea, central
cyanosis (a late sign),
confusion, adventitious
breath sounds, use of
accessory muscles
when breathing.
Rationale:
- Consult appropriate
health care provider
(e.g. physician,
respiratory therapist) if
signs and symptoms of
impaired respiratory
function persist or
worsen.
- Maintain oxygen
therapy as ordered
Rationale:Maintaining
oxygen therapy is an
important first step to
reduce symptoms of
pulmonary edema.
- Encourage deep
breathing and incentive
spirometry.
Rationale:
These exercises
maintain & increase
lung capacity.

Impaired homeostasis r/t

Hypertension

Ascites r/t
Impaired
homeostasis

- Weigh as indicated.
Compare changes in
fluid status, recent
weight history, and
skinfoldmeasurement.
Rationale: It may be
difficult to use weight as
a direct indicator of
nutritional status in view
of edema and/or ascites.
Skinfold measurement is
useful in assessing
changes in muscle mass
and subcutaneous fat
reserves.
- Give small, frequent
meals.
Rationale: Poor
tolerance to larger meals
may be due to increased
intra-abdominal pressure
and ascites.
- Promote undisturbed
rest periods, especially
before meals.
Rationale: Conserving
energy reduces
metabolic demands on
the liver and promotes
cellular regeneration.
- Once blood is taken,
monitor laboratory
studies: serum glucose,
prealbumin and albumin,
total protein, ammonia.
Rationale: Glucose may
be decreased because of
impaired
gluconeogenesis,
depleted glycogen stores,
or poor intake. Protein
may be low because of
impaired metabolism,
decreased hepatic
synthesis, or loss into
peritoneal cavity
(ascites). Elevation of
ammonia level may
require restriction of
protein.
-Monitor for infection
(peritonitis/puritis).
Check if urine samples
and blood cultures are
ordered.
Rationale: bacterial
peritonitis occurs
because antibodies are
rare in ascites and
immune response in
ascetic fluid is limited.

Hypertension begins in liver

as portal hypertension
(cirrhotic liver)

Jaundice r/t
hepatic
decompensation

- Monitor direct and

indirect bilirubin
once lab work is
available.
Rationale: portal
hypertension causes
a build up of
bilirubin (hepatic
decompensation).
- Assess skin color.
Note the amount of
body affected by
jaundice/colour/ etc.
Rationale: Skin
colour assessments
can help to
determine the
severity of
hyperbilirubinemia.
- Change or
encourage position
change every two
hours to maintain
skin integrity.
Rationale:Jaundice
causes the patient to
become more
susceptible to skin
ulcers and tears. The
increased levels of
bilirubin causes skin
weakness.
- Maintain patients
body image.
Encourage the
patient to create
attainable goals.
Rationale:Patient
may have an altered
body image. Assess
the patients
psychiatric status
and their need for
counselling r/t
condition and
involve patient in
their care.
- Keep skin clean
and moisturized.
Rationale:Jaundice
puts the patient at
risk for impaired
skin integrity.
Keeping the skin
moisturized and
clean will prevent
lesions and ulcers
from forming which
can impede recovery
and lead to infection.

At risk for
confusion r/t
hepatic
decompensation

- Pt. teaching r/t to

confusion caused by
disease process.
Rationale:
Confusion occurs as a
result of liver
cirrhosis.
Precipitating factors
must be recognized
before they occur
such as: infections,
kidney failure,
electrolyte
abnormalities, and
gastrointestinal
bleeding.
-Reduce protein level
to lower ammonia
production.
Rationale:Ammonia
can damage the
nervous system and
cause patients to
experience confusion.
- Increase intake of
items increasing
motility.
Rationale:The high
fiber content of a
vegetable diet can
increase motility,
altering acidity in the
intestines, and
therefore reducing the
absorption of
ammonia. Lactulose
(non-absorbable
sugar) changes
ammonia to
ammonium in the
colon to be excreted.
- Control production
of ammonia. Ensure
ordered antibiotics
are administered.
Rationale:
Antibiotics like
Neomycin and
Metrondiazole can
control the growth of
bacteria that produces
ammonia in the
colon.
-Thiamine should be
given when possible
(based on doctor
orders).
Rationale: A lack of
thiamine can cause a
neurologic disorder
that can also cause
confusion.

Complex Issue & Patient Safety

The patient presented with a history of cirrhosis of the liver and a history of ETOH for 25
years. The patients vital signs were abnormal: blood pressure 162/74, O2 Sat 92%, pulse 122,
respiratory rate of 26, and temperature of 37.5 C. The patient is also experiencing ascites which
is impeding the patients lung expansion. If the patients lung expansion is impaired, the patient
will experience tachypnea. Tachypnea and shortness of breath puts the patient in immediate risk
and is life-threatening. A pathophysiological priority, clinical manifestation/complication related
to the priority and nursing interventions will be discussed for this patient.
Chosen pathophysiological priority
When conducting a critical assessment of the patient, it can be determined that the
pathophysiological priority for the patient in the case scenario is increased respiratory rate
(impaired lung expansion) related to ascites. Ascites is one of the most common causes of
decompensation and has a negative impact on mortality (Gomez, Gonzalez, Bertot, Garcia, &
Rodriguez, 2014). The patient in the case scenario is cirrhotic. The most common cause of
ascites is cirrhosis (Gomez et al., 2014). The patient is also both hypertensive at 162/74 and
tachycardic at 122 beats per minute. Hypertension is not a protective factor against ascites
(Gomez et al., 2014). When cirrhosis is compensated, circulatory dysfunction is a crucial part of
ascites development (Gomez et al., 2014). The circulatory dysfunction causes a decrease in the
effective circulating volume, which causes neurohumoral activation with sodium and water
retention (Gomez et al., 2014). The sodium and water retention also explains the patients
generalized edema. Generalized edema is an indication of heart failure because blood is being
pumped less efficiently and fluid is building up (Dieplinger, Gegenhuber, Kaar, Poelz,
Haltmayer, & Mueller, 2010). Therefore, congestive heart failure can cause ascites to occur. In
ascites, neurohormonal excitation increases, sodium is retained, and plasma volume expands

Complex Issue & Patient Safety

(Gomez et al., 2014). Fluid then accumulates is the peritoneal cavity (Gomez et al., 2014). As
more fluid accumulates in the abdomen, there is increased pressure on the diaphragm and the
migration of the fluid across the diaphragm causes pleural effusions (Gomez et al., 2014). Pleural
effusions decrease a patients ability for lung expansion (Singh, Bajwa, &Shujaat, 2013).
Shortness of breath and liver cirrhosis also causes a serious disease known as hepatic
hydrothorax (Woo, Chung, Baik, & Kim, 2015). Hepatic hydrothorax is when a significant
pleural effusion occurs (Woo et al., 2015).Therefore, difficulty breathing is a known
complication of ascites (Palaniyappan&Aithal, 2014). The patients diagnosis of ascites puts the
patient at risk of developing dyspnea (Gomez et al., 2014). Therefore, an increased respiratory
rate related to ascites is a pathophysiological priority for this patient.
Clinical Manifestation/Complication
The clinical manifestation or complication of increased respiratory rate is shortness of
breath. Difficulty breathing is a predictor of mortality and should be treated as a priority
(Figarska, Boezen, &Vonk, 2012). In fact, shortness of breath is a symptom that causes many
patients to go to the emergency department (Dieplinger et al., 2010). Shortness of breath on
exertion is often associated with poor health outcomes (Figarska et al., 2012) especially in
patients with cirrhosis (Perumalswami&Schiano, 2011). Figarska et al. (2012) concluded that the
higher the severity of dyspnea, the higher the mortality risk. Furthermore, the patient is
experiencing an increased respiratory rate of 26 which puts the patient at risk of increased
shortness of breath.Creitkos, Bellomo, Hillman, Chen, Finfer, &Flabouris (2008) states that a
patient with a respiratory rate over 24 breaths per minute is likely to be critically ill. Respiratory
rate is considered to be important because alveolar ventilation is normally controlled by the
central and peripheral chemoreceptors and lung receptors (Creitkos et al., 2008). Ventilation is

Complex Issue & Patient Safety

driven by both arterial partial pressure of oxygen and arterial partial pressure of carbon dioxide
(Creitkos et al., 2008, p. 14). The human body tries to correct hypoxemia and hypercarbia by
increasing respiratory rate (Creitkos et al., 2008). Also, conditions that cause metabolic acidosis
will precipitate an increase in respiratory rate and leads to increased carbon dioxide production
(Creitkos et al., 2008). It is also important to consider the O2 Sat of 92% which is reduced arterial
hemoglobin saturation (Creitkos et al., 2008). Even though the patient has increased there
respiratory rate to compensate for a decrease in oxygen, the patients O2 Sat is not reflective of
this (Creitkos et al., 2008).Ascites causes shortness of breath because as fluid accumulates in the
abdomen, pleural effusions occur (Gomez et al., 2014). Shortness of breath is a clinical
manifestation of ascites (Gomez et al., 2014).
Nursing Interventions
There are many nursing interventions that should be implemented to treat both the
pathophysiological priority and the clinical manifestation. The first intervention to be
implemented would be initiation of oxygen therapy if the patient is in distress or O2sats are
below a therapeutic range (<89%)(Creitkos et al., 2008).Oxygen saturations <89% may cause
cyanosis, increase workload of the heart, and cause cardiac arrest (Creitkos et al., 2008). It is
imperative to maintain the oxygen saturations of the patient so that not of the listed implications
occur (Creitkos et al., 2008). Other nursing interventions include the discontinued use of some
substances. Hepatic hydrothorax is caused by cirrhosis (Singh et al., 2013). Cirrhosis of the liver,
in the case of this patient, was caused by excess alcohol consumption over 25 years. The patient
needs to decrease consumption of alcohol or stop consuming alcohol altogether
(Palaniyappan&Aithal, 2014). It is priority that the patient stops consuming alcohol to prevent
further damage (Palaniyappan&Aithal, 2014). The patient also needs to discontinue taking any

Complex Issue & Patient Safety

nonsteroidal anti-inflammatory medications (NSAIDs). NSAIDs are metabolized in the liver

which puts the liver at risk of further development of cirrhosis, which leads to ascites, which
causes shortness of breath (Muir, 2015). Since the pathophysiological priority is ascites, which
is causing the complication of shortness of breath, the ascites will have to be managed. In order
to decrease the ascites that is occurring, the patient may need either oral diuretic, therapeutic
paracentesis, or a transjugular portosystemic shunt (TIPS) (Singh et al., 2013;
Perumalswami&Schiano, 2011). Oral diuretics will cause the kidneys to perfuse more and
excrete more fluids (Zama & Edgar, 2012). By taking oral diuretics, the patient will decrease his
blood pressure and remove excess fluid from his body which will also aid with the generalized
edema (Zama & Edgar, 2012). Paracentesis is a procedure which directly moves fluid out of the
abdominal cavity (Zama & Edgar, 2012). A TIPS procedure shunts fluid from the peritoneal
cavity to an organ that can remove the fluid from the body (Perumalswami&Schiano, 2011).
These procedures allow for the removal of fluids which will decrease pleural effusions, therefore
allowing the diaphragm to expand fully and decrease shortness of breath
(Perumalswami&Schiano, 2011).
The patients pathophysiological priority is increased respiratory rate related to ascites.
The main clinical manifestation/complication to be addressed with this patient is shortness of
breath. Nurses can advocate, provide teaching, and implement interventions that can decrease the
effect of the priority and manage the complication. Nurses provide holistic evidence and theory
based care for clients with multiple physical concerns by using critical thinking, problem
solving, and decision making skills.

Complex Issue & Patient Safety

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Complex Issue & Patient Safety

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fistula mimicking re-expansion pulmonary edema during liver transplantation: a case
report. Korean journal of anesthesiology, 68(2), 184-187.
Zama, I. N., & Edgar, M. (2011). Management of Syptomatic Ascites in Hospice Patients with
Paracentesis: A Case Series Report. American Journal of Hospice and Palliative
Medicine, 1049909111420130.