Medical Surgical Esophageal varices #1

Question

A client with advanced cirrhosis is admitted to the intensive care unit. Which assessment will the nurse prioritize when developing the plan of care?

Answers

  1. Assessing for jaundice.
    • Rationale:

      While it is important to assess the client for jaundice, this is not the priority based on the diagnosis and the ABCs (airway, breathing, circulation). Mortality increases for acute bleeding and recurrence of bleeding. This makes the assessing for variceal bleeding a priority with cirrhosis.

  2. Assessing for variceal bleeding.
    • Rationale:

      Based on the ABCs (airway, breathing, circulation), the priority action by the nurse is to assess the client for variceal bleeding. Hemorrhage accounts for increased morbidity and mortality for the client who is diagnosed with cirrhosis.

  3. Monitoring liver function tests daily.
    • Rationale:

      While monitoring the client’s liver function tests daily is important, this is not the priority based on the diagnosis and the ABCs (airway, breathing, circulation). Mortality increases for acute bleeding and recurrence of bleeding. This makes the assessing for variceal bleeding a priority with cirrhosis.

  4. Measuring weight and abdominal girth.
    • Rationale:

      While measuring the client’s weight and abdominal girth is important, this is not the priority based on the diagnosis and the ABCs (airway, breathing, circulation). Mortality increases for acute bleeding and recurrence of bleeding. This makes the assessing for variceal bleeding a priority with cirrhosis.

Overview

Cirrhosis is a late stage of scarring (i.e., fibrosis) of the liver caused by many different liver diseases and conditions (e.g., hepatitis, chronic alcoholism).

Explanation

Learning Outcomes

Esophageal varices occur in 30% of clients with compensated cirrhosis and 60% with decompensated cirrhosis. They are the main source of bleeding and will increase mortality rates with the first bleeding episode. Mortality increases for acute bleeding and recurrence of bleeding. This makes the assessing for variceal bleeding a priority with cirrhosis.

Test Taking Tip

Consider the ABCs (airway, breathing, circulation) when asked to prioritize nursing interventions.

Video Rationale