NURSING CARE PLAN CUES Subjective Cues ³Maglisod ko¶g ginhawa, ilabina ug mag higda, kailangan, nay unlan sa ako ulo.´ As verbalized by patient.
NURSING DIAGNOSIS Excess
Fluid Volume r/t compromised regulatory mechanism (organ failure) secondary to liver cirrhosis
OBJECTIVE Short term objective: Within 8 hours of applying appropriate nursing interventions, pt. will be able to verbalize understanding of individual dietary and fluid restrictions. restrictions. Long term objective:
Objective Cues >edema >dyspnea >restlessness >decreased hemoglobin >decreased hematocrit >altered electrolytes T: 37.0 c P: 92 bpm R: 20 cpm BP: 120/80 mmHg
After 3 days of applying appropriate nursing interventions, pt. will be able to stabilize fluid volume as evidenced by I & O, vital signs, stable weight, and free of signs of edema.
INTERVENTION
RATIONALE
EVALUATION
>Note presence of medical conditions that potentiate fluid e xcess
>To assess causative/precipitating factor
Short term objective: Outcome met
>Assess degree of peripheral edema
>Fluid shift in the tissues as a result of sodium and water retention
>Compare current weight with admission and/or previously stated weight >Measure abdominal girth for changes that may indicate increase fluid retention or edema >Weigh daily or on a regular schedule
r
>Encourage bed rest when ascites is present
>To evaluate degree of excess >To evaluate severity of fluid retention/edema >provides comparative baseline and evaluates effectiveness of diuretic therapy when used >May promote recumbency-induced diuresis
Within 8 hours of applying appropriate nursing interventions, pt. was able to verbalize understanding of individual dietary and fluid restrictions. restrictions. Long term objective: Outcome partially Met After 3 days of applying appropriate nursing interventions, pt. was partially able to stabilize fluid volume as evidenced by I & O, vital signs, stable weight, and free of signs of edema.
NURSING CARE PLAN CUES Subjective Cues ³Sakit jud japun akung tiyan, wala gyud ko katulog gabii´ as verbalized by pt. P-upon sudden movement Q-sharp stabbing pain R-originates @ the epigastric & abdominal area RUQ and radiates to the right and lower lumbar area S-8/10 T-intermittent occurs twice q h for 15 mins.
Objective Cues >restlessness >guarding behavior >facial grimace >frequent changes of position T: 37.0 c P: 92 bpm R: 20 cpm BP: 120/80 mmHg r
NURSING DIAGNOSIS Acute Pain r/t presence of fluid on peritoneal cavity 2° liver cirrhosis
OBJECTIVE Short term objective: Within 8 hours of applying appropriate nursing interventions, pt. will be able to identify and demonstrate nonpharmacologic methods that provide relief.
INTERVENTION
RATIONALE
EVALUATION
>Use pain rating scale, w/ 10 as the highest
>To evaluate severity of pain sensation
Short term objective: Outcome met
>Accept clients description of pain
>Pain is a subjective experience and cannot be felt by others
>Provide information to client that tough therapy could help in providing relief
Long term objective: After 3 days of applying appropriate nursing interventions, pt. will be able to report pain has subsided.
>Inform patient that repositioning could be a help >Instruct patient to think of distracting attention when pain occurs
Within 8 hours of applying appropriate nursing interventions, pt. was able to identify >Touch therapy and demonstrate nonpromotes numbness of pharmacologic the area methods that provide relief. >Repositioning promotes comfort and Long term objective: somehow provides relief. Outcome Met >So that pain will be diverted >to prevent fatigue
>Encourage adequate rest periods
After 3 days of applying appropriate nursing interventions, pt. was able to report pain has subsided..
NURSING CARE PLAN CUES Subjective Cues ³katol man ni akong tiil day mao akong gina katol´ as verbalized by patient
Objective Cues >presence of edema on lower e xtremities >poor skin turgor >disrupted skin surface; dorsal part of left foot >striae >decreased sensation on edematous area T: 37.0 c P: 92 bpm R: 20 cpm BP: 120/80 mmHg r
NURSING DIAGNOSIS
OBJECTIVE
Impaired Skin Integrity r/t overstretching of skin tissues in the lower extremities 2 disease process r
Short term objective: Within 8 hours of applying appropriate nursing interventions, pt. will be able to identify individual techniques to prevent further skin breakdown. Long term objective: After 3 days of applying appropriate nursing interventions, pt. will be able to display timely healing of disrupted skin.
INTERVENTION
RATIONALE
EVALUATION
>Inspect skin surfaces routinely
>edematous tissues are more prone to breakdown & to the formation of decubitus. Ascites may stretch the skin to the point of tearing in severe cirrhosis.
Short term objective: Outcome met
>Limit use of soap for bathing and emollient lotions
>Encourage/assist with repositioning on a regular schedule, while in bed/chair as appropriate
>repositioning reduces pressure on edematous tissues to improve circulation
>Recommend elevating of the lower extremities
>enhances venous return and reduces further edema formation in extremity
>Advise patient and SO to keep linens dry and free of wrinkles
>moisture aggravates pruritus and increases risk of skin breakdown
Within 8 hours of applying appropriate nursing interventions, pt. was able to identify individual techniques to prevent further skin breakdown.. Long term objective: Outcome partially Met After 3 days of applying appropriate nursing interventions, pt. was able to partially display timely healing of disrupted skin.
