A client is being treated for hepatic failure. On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated pulse rate. Which intervention should the nurse include in the plan of care?

A client is being treated for hepatic failure. On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated pulse rate. Which intervention should the nurse include in the plan of care?

• A. Review arterial blood gases results.
• B. Assess for dependent pitting edema.
• C. Document abdominal girth.
• D. Record usual eating patterns.

Answer: (B)

In hepatic failure, fluid shifts into the tissues because of low albumin and increased pressure in the liver’s venous system, so rapid weight gain and a faster pulse point to fluid overload. The most helpful immediate assessment is checking for dependent pitting edema. By pressing on the lower legs or ankles and noting whether a lasting dent remains, you get a direct, practical gauge of peripheral fluid status and how it’s changing over time. This information guides decisions about fluid management, diuretics, and monitoring. Reviewing arterial blood gases would focus on gas exchange and acid-base balance, not directly on how much fluid has accumulated. Documenting abdominal girth could track ascites, which is important but peripheral edema often develops first and reflects overall fluid overload. Recording usual eating patterns doesn’t address the acute change in fluid status seen with this presentation.

In hepatic failure, fluid shifts into the tissues because of low albumin and increased pressure in the liver’s venous system, so rapid weight gain and a faster pulse point to fluid overload. The most helpful immediate assessment is checking for dependent pitting edema. By pressing on the lower legs or ankles and noting whether a lasting dent remains, you get a direct, practical gauge of peripheral fluid status and how it’s changing over time. This information guides decisions about fluid management, diuretics, and monitoring.

Reviewing arterial blood gases would focus on gas exchange and acid-base balance, not directly on how much fluid has accumulated. Documenting abdominal girth could track ascites, which is important but peripheral edema often develops first and reflects overall fluid overload. Recording usual eating patterns doesn’t address the acute change in fluid status seen with this presentation.