Table 2. Monitoring protocol.

Part A. Case history/Pre-conditioning nursing assessment
Take vital signs: arterial pressure, heart rate, respiratory rate, body temperature, oxygen saturation Measure weight (define 5% threshold value) Abdominal assessment (visual and by palpation), in particular of the RUQ: record spontaneous and induced pain (Blumberg), record abdominal circumference, abdominal volume, the presence of collateral circles and/or spiders, tractability, percussion (obtuseness), the assessment of hepatic RIMA and dimensions of the liver, assessment of hepatic consistency Assessment of skin: erythema, lesions, haemorrhages, dyschromia (jaundice) Assessment of sclera: microhaemorrhages, jaundice Consider blood test values: total and fractionated bilirubin, transaminases, LDH, electrolytes (Na, K) Details of patient’s clinical history, personal habits (diet, smoking, alcohol) and social background
Assignment of standard or increased risk level Alert for the confirmation of risk level on admission
Standard risk		Increased risk
At least once a day Weight Abdominal circumference Abdominal pain and RUQ pain Objective examination of skin, sclera, abdomen (palpation) Fluid balance At least twice a week and whenever significant variations in clinical signs are observed Measurement of bilirubin, transaminases, sodium, potassium, coagulation parameters		At least twice a day Weight State of awareness Abdominal circumference Abdominal pain and RUQ pain Objective examination of skin, sclera, abdomen (palpation) Fluid balance Between three times a week to every day whenever significant variations in clinical signs are observed Measurement of bilirubin, transaminases, sodium, potassium, coagulation parameters
Report even small changes in clinical condition in a timely fashion Educate patient and CGs in timely communication		Report even small changes in clinical condition in a timely fashion Educate patient and CGs in timely communication
Part B. Patients who meet the modified Seattle and Baltimore criteria: Intensified Monitoring Protocol
At least twice a day State of awareness Abdominal circumference Full objective examination of abdomen, sclera, skin, and mucosae	At least three times a day Weight Pain in RUQ Monitor for appearance of signs of haemorrhage (skin, sclera, mucosae	At least four times a day Fluid and electrolyte balance Oxygen saturation Vital signs: arterial pressure, heart and respiratory rate, body temperature
Foresee the need for continuous monitoring of parameters Intensify monitoring of blood tests: fractionated bilirubin, transaminases, coagulation parameters, sodium, potassium, and other tests prescribed by the doctor Provide psychological support for patient and family members or CGs
Part C. Patients with a diagnosis of VOD: High-intensity monitoring protocol
At least twice a day Abdominal circumference Full objective examination of abdomen, sclera, skin and mucosae	At least three times a day Weight Pain in RUQ Monitor for the appearance of signs of haemorrhage (skin, sclera, mucosae)	At least four times a day Fluid and electrolyte balance
Consider patient as critical
Continuous monitoring of vital signs using monitors: arterial pressure, heart rate, respiratory rate, body temperature, oxygen saturation. Ventilatory support if necessary: oxygen therapy or non-invasive ventilation Ensure drastic reduction in fluid intake Ensure appropriate number of vascular access points Frequently monitor diuresis, possible use of bladder catheter with urometer Evaluate performance status and state of awareness Monitor for MOF: cardiac, respiratory, and renal function Provide psychological support for patient and family members or CGs Make arrangements for rapid transfer to CU

RUQ: right upper quadrant; LDH: lactic dehydrogenase; CGs: care givers; MOF: multiple organ failure; ICU: intensive care unit.