The nurse is caring for a 58-year-old client who was admitted to the medical unit with liver cirrhosis. Highlight three findings that require immediate follow up. History and Physical The client is a 58-year-old admitted to the medical unit with a known history of liver cirrhosis secondary to chronic alcohol use. Client reports progressive abdominal swelling over the past several weeks associated with increasing fatigue, early satiety, and generalized weakness. Client reports pruritus that has worsened over the past week and intermittent shortness of breath when lying flat. Family reports increasing confusion at home over the past 2 days, including difficulty concentrating and forgetfulness. On assessment, the client is alert and oriented x3 but appears fatigued. Scleral icterus and generalized jaundice are noted. Abdomen is markedly distended with positive fluid wave consistent with ascites. Lower extremity edema is present. Breath sounds are diminished at the bases with shallow respirations. Skin is dry with scratch marks noted from itching. Nurses' Notes 0920: Client admitted to the medical unit yesterday for severe ascites. Sitting in bed. Alert and oriented x 3 (person, place, situation). No adventitious breath sounds but shallow respirations. S1 and S2 present; no murmurs. Bowel sounds present x 4 but distant. Abdomen very distended due to ascites. Can move all extremities but reports weakness. Cap refill <3 sec. Skin dry with jaundice; icterus present. Reports frequent pruritis. VS: T 99.2°F (37.3°C); HR 96 BPM; RR 24 bpm; B/P 98/58 mmHg; SpO2 94% on 4 L/min 02 via NC.

The client presents with findings in advanced liver cirrhosis complicated by ascites and possible fluid volume shifts. Cirrhosis leads to impaired protein synthesis, portal hypertension, and third-spacing of fluid, which can significantly affect oxygenation and hemodynamic stability. Clients are at risk for respiratory compromise due to ascites limiting lung expansion and for hypotension due to reduced vascular resistance and fluid imbalance. Identifying the most critical physiologic parameters ensures early detection of deterioration. Rationale for correct choices: &bull; Oxygen saturation is a priority because the client has diminished breath sounds at the bases and shallow respirations, likely due to ascites limiting diaphragmatic expansion. Fluid accumulation in the abdomen can restrict lung expansion, leading to impaired gas exchange. Monitoring SpO₂ helps detect early hypoxemia and respiratory compromise. &bull; Blood pressure (98/58 mmHg): Low blood pressure is a significant concern in cirrhosis due to decreased albumin production and fluid shifts into the peritoneal cavity (third spacing). Hypotension may indicate decreased effective circulating volume and risk for poor organ perfusion. The client is already on diuretics, which can further lower intravascular volume. Monitoring blood pressure is essential to prevent circulatory collapse and renal hypoperfusion. &bull; Confusion at home is clinically significant in a client with liver cirrhosis because it suggests hepatic encephalopathy, which is a common and potentially serious complication. In liver cirrhosis, the liver loses its ability to properly detoxify substances, especially ammonia, which builds up in the bloodstream and crosses into the brain, affecting neurotransmission and cerebral function. This leads to early neurocognitive changes such as difficulty concentrating, forgetfulness, personality changes, and disorientation. Rationale for incorrect choice: &bull; Scleral icterus and jaundice: Jaundice is an expected chronic finding in liver cirrhosis due to impaired bilirubin metabolism. While it reflects disease severity, it is not an acute or life-threatening change requiring immediate intervention. It indicates ongoing liver dysfunction rather than acute deterioration. Therefore, it is not a priority compared to ascites or encephalopathy. &bull; Pruritus: Pruritus is a common symptom in liver disease caused by bile salt accumulation in the skin. Although uncomfortable and requiring symptom management, it is not life-threatening. It does not indicate acute decompensation or organ failure. Therefore, it is a lower priority compared to neurological or respiratory complications.