Analyze Nursing Diagnoses

Nursing Diagnosis:

1. Imbalance nutrient: less than body requirement
     related inadequate diet; inability to process/digest nutrients

2. Excess fluid volume
    related to fluid retention

3. Impair skin integrity
    related to altered circulation/metabolic state, accumulation of bile salts in skin and poor skin turgor


4. Ineffective breathing pattern
     related to (ascites), decreased lung expansion from accumulated fluid and decrease energy

    
5.  Alter fluid and electrolyte imbalance
     related to portal hypertension

Actual or potential Nursing Diagnosis	Impair Skin Integrity
Related to	Altered circulation/metabolic state Accumulation of bile salts in skin Poor skin turgor
Plan and outcome	Maintain skin integrity Identify individual risk factors and demonstrate behavior/techniques to prevent skin breakdown
Nursing intervention	Inspect pressure points and skin surfaces closely and routinely. Gently massage bony prominences or areas of continued stress. Use of emollient lotions and limiting use of soap for bathing may help. Encourage and assist patient with reposition on a regular schedule. Assist with active and passive ROM exercises as appropriate  Recommend elevating lower extremities.  Keep linens dry and free of wrinkles.

Nursing Diagnosis References:
http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?disid=17
http://wps.prenhall.com/wps/media/objects/737/755395/alcoholic_cirrhosis.pdf