Nursing Care Plan
Assessment
Subjective: “Napansin ko na lumalaki ang tiyan ko” as verbalized Objective: Pallor Weak in appearance Jaundice Abdominal distention noted Bipedal edema Irritability noted DOB with RR of 29 bpm Abdominal girth of 32”
Diagnosis
Fluid volume excess r/t compromised regulatory mechanism secondary to cirrhosis of the liver as manifested by pallor, weak in appearance, jaundice, abdominal distention, edema, irritability, DOB with RR of 29 and abdominal girth of 32”
Planning
After 6 hours of nursing interventions, patient will demonstrate stabilized fluid volume and decreased edema and abdominal girth.
Interventions
Rationale
Monitor vital sign
Measure intake and output
Monitor BP
Assess respiratory status Monitor abdominal girth Provide occasional ice chips if NPO
Restrict sodium and fluids as ordered
Established baseline data Reflects circulating volume status, developing fluid shifts, and in response to therapy BP elevations are usually associated with fluid volume excess Indicative of pulmonary congestion/edema Reflects accumulation of fluid (ascites) Decreases sensation of thirst, especially when fluid intake is restricted Sodium may be restricted to minimize fluid retention in extravascular spaces. Fluid
Evaluation
After 6 hours of nsg. interventions, the patient demonstrated stabilized fluid volume and decreased edema and abdominal girth.
Goal met.
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restriction may be necessary to prevent dilutional hyponatremia
Administer medications as indicated: Diuretics
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Potassium
Assist with paracentesis procedure
Used with caution to control edema and ascites, block effect of aldosterone, and increase water excretion while sparing potassium Serum and cellular potassium are usually depleted because of liver disease Done to remove ascites fluid
Nursing Care Plan
Assessment
Subjective: “Wala akong ganang kumain” as verbalized Objective: Weak in appearance Refusal to eat Irritability noted Poor muscle tone Jaundice noted Emaciated Abdominal distention noted Pallor noted
Diagnosis
Imbalance nutrition: less than body requirements r/t loss of appetite secondary to ascites as evidenced by refusal to eat, weak in appearance, irritability, poor muscle tone, emaciated and abdominal distention
Planning
After 5 hrs of nsg. Interventions, patient’s appetite will improve from 2 tbsp to at least 5 tbsp per meal.
Interventions
Rationale
Monitor vital signs
For baseline data
Assist in oral hygiene before meals. Discuss eating habits including food preferences. Serve favorite foods that are not contraindicated. Prevent or minimize unpleasant odors during meal time. Serve foods that are attractive and palatable. Recommend small, frequent meals
A clean mouth enhances appetite To appeal to client likes and dislikes
Restrict intake of caffeine, gasproducing or spicy and excessively hot or cold foods
To stimulate the appetite May have negative effect on appetite To stimulate the appetite Poor tolerance to larger meals may be due to increased intraabdominal pressure/ascites Aids in reducing gastric irritation & abdominal discomfort that may impair oral intake/digestion
Evaluation
After 8 hours of nursing interventions, patient’s appetite improved from 2 tbsp to 5 tbsp per meal. Goal met.
Provide assistance with activities as needed. Promote undisturbed rest periods, especially before meals Advise to consume nutritious foods
Conserving energy reduces metabolic demands on the liver and promotes cellular regeneration.
Nursing Care Plan
Assessment
Subjective: “Sumasakit ang tiyan ko” as verbalized with a pain scale of 6 out of 10 where in: 0 - no pain 1 – 2 mild pain 3 – 4 moderate pain 5 – 6 severe pain 7 – 8 very severe pain 9 – 10 worst possible Objective: Facial grimace noted Irritability noted Restlessness noted Anxiety noted Fatigued Clenched fist “Beaten” look Agitation noted Pallor Grunting Guarding of body part (right hypochondriac)
Diagnosis
Acute pain related to liver enlargement secondary to ascites as evidenced by facial grimace, irritability, restlessness, anxiety, fatigued, clenched fist, “beaten” look, agitation, pallor, grunting, guarding of body part and verbalization of pain with a pain scale of 6/10
Planning
After 2 hours of nursing interventions, pain will be lessened with a scale of 1-10, from 6/10 to 1/10.
Interventions
Monitor VS Perform pain assessment (COLDSPA) every time pain occurs
Rationale
Encourage verbalization of feeling of pain
Instruct use of relaxation exercise such as listening to music Provide comfort measures such as back rubbing & changing position Teach the patient relaxation techniques like deep breathing Provide quiet and calm environment
Pain alters VS To rule out development of complications by knowing alleviating and precipitating factors Pain is subjective & can’t be assessed through observation alone Promotes relaxation and diverts attention from pain To prove nonpharmacological management To alleviate pain
Noisy environment stimulates irritation
Evaluation
After 2 hours of nursing interventions, patient was relieved from pain Goal met.
Nursing Care Plan
Assessment
Subjective: “Nahihirapan akong huminga” as verbalized Objective: Dyspnea Tachypnea with RR of 30, irregular, shallow Weak in appearance Anxiety noted Irritability noted Restlessness noted Lethargic Pallor
Diagnosis
Altered breathing pattern r/t decreased lung expansion secondary to intraabdominal fluid collection (ascites) as manifested by dyspnea, tachypnea with RR of 30, irregular and shallow, weak in appearance, anxiety, irritability, restlessness, lethargy and pallor
Planning
After 6 hours of nursing interventions, patient will be relieved from dyspnea and breathing pattern will return to normal.
Interventions
Monitor V/S Monitor respiratory rate, rhythm and depth
Auscultate breath sounds, noting crackles, wheezes and rhonchi Investigate changes in LOC
Rationale
Keep head of bed elevated. Position on sides Encourage frequent repositioning and deep-breathing exercises Provide supplemental O2 as indicated
For baseline data Rapid shallow respirations/dyspn ea may be present because of hypoxia or fluid accumulation in the abdomen Indicates developing complications and increasing risk of infection Changes in mentation may reflect hypoxemia and respiratory failure Facilitates breathing by reducing pressure on the diaphragm Aids in lung expansion and mobilizing secretions May be necessary to treat/prevent
Evaluation
After 6 hours of nsg. interventions, patient was relieved from dyspnea and breathing pattern returned to normal Goal met.
hypoxia
Nursing Care Plan
Assessment
Diagnosis
Planning
Interventions
Rationale
Evaluation
Subjective: “Nanghihina na ako, ayoko na mag-gagalaw” as verbalized Objective: Pallor Body malaise noted Diaphoresis Inability to concentrate Inability to perform usual ADLs Weak in appearance Limited ROM Difficulty initiating movements
Activity intolerance r/t generalized body weakness secondary to progressive disease state as manifested by pallor, body malaise, diaphoresis, inability to concentrate, inability to perform usual ADLs, weak in appearance, limited ROM and difficulty initiating movements
After 8 hours of nursing interventions, patient will participate willingly in necessary activity, will learn how to conserve energy and verbalize relief from fatigue.
Evaluate pt’s current activity tolerance Adjust activity and reduce intensity of task that may cause undesired physiological changes Increase exercise and activity levels gradually Teach methods to conserve energy such as sitting than standing while dressing Demonstrate/Assis t the patient while doing ADL Give the patient information that provides evidence progress Encourage client to do whatever possible e.g. selfcare
Provide cooperative baseline To prevent over exertion
Enhances activity tolerance
Helps minimize waste of energy
Protect patient from injury To sustain pt’s motivation
Provides for sense of control and feeling of accomplishment
After 8 hours of nursing interventions, patient participated willingly in necessary activities, learned how to conserve energy and verbalized relief from fatigue Goal met
Nursing Care Plan
Assessment
Subjective: “Mawawala ba pa ‘tong laki ng tiyan ko?” as verbalized Objective: Anxiety noted Fear of rejection Irritability noted Restlessness noted Feeling of helplessness Negative feelings about body
Diagnosis
Disturbed body image r/t altered physical appearance as evidenced by anxiety, fear, irritability, restlessness, feeling of helplessness and negative feelings about the body
Planning
After 8 hours of nursing interventions, patient will verbalize understanding of changes and acceptance of self in the present situation.
Interventions
Discuss situation/encourag e verbalization of fears and concerns. Explain relationship between nature of disease and symptoms.
Support and encourage patient; provide care with a positive, friendly attitude
Encourage family to verbalize feelings, visit freely/participate in care
Rationale
Patient is very sensitive to body changes and may also experience feelings of guilt when cause is related to alcohol (70%) or other drug use. Caregivers sometimes allow judgmental feelings to affect the care of patient and need to make every effort to help patient feel valued as a person. Family members may feel guilty about patient’s condition and may be fearful of impending death. They need nonjudgmental emotional support and free access to patient. Participation in care
Evaluation
After 8 hours of nursing interventions, patient verbalized understanding of changes and acceptance of self in the present situation. Goal met
helps them feel useful and promotes trust between staff, patient.
Nursing Care Plan
Assessment
Diagnosis
Planning
Interventions
Rationale
Evaluation
Subjective: “Lagi akong nangangati at parang mahapdi balat ko” as claimed Objective: Pruritus noted Dry skin Erythema noted Scaly skin
Risk for impaired skin integrity r/t altered circulation secondary to accumulation of bile salts as evidenced by pruritus, erythema, dry and scaly skin
After 7 hours of nursing interventions, patient will maintain skin integrity and identify individual risk factors and demonstrate behaviors/techniqu e to prevent skin breakdown.
Inspect skin surface/pressure points routinely. Gently massage bony prominences or areas of continued stress
Encourage/assist with repositioning on a regular schedule while in bed, chair and active passive ROM exercises as appropriate
Keep linen dry and free of wrinkles
Suggest clipping finger nails short
Edematous tissues are more prone to breakdown and to the formation of decubitus ulcers. Ascites may stretch the skin to the point of tearing in severe cirrhosis Repositioning reduces pressure on edematous tissues to improve circulation. Exercises enhance circulation and improve, maintain, joint mobility Moisture aggravates pruritus and increases risk of skin breakdown Prevents client from inadvertently injuring the skin especially while sleeping
After 3 hours of nursing interventions, patient maintained skin integrity and identified individual risk factors and demonstrated behaviors/techniqu es to prevent skin breakdown. Goal met
Nursing Care Plan
Assessment
Subjective: “Nahiirapan akong umihi” as verbalized Objective: Anxiety noted Irritability noted Restlessness noted Small, frequent voiding Facial grimace noted upon urination Excessive diaphoresis when trying to void Urgency
Diagnosis
Impaired urinary elimination r/t bladder distention secondary to ascites as evidenced by anxiety, irritability, restlessness, small and frequent voiding, facial grimace upon urination, excessive diaphoresis when trying to void, and urgency
Planning
After 8 hours of nursing interventions, patient will empty bladder regularly with decrease pain and difficulty.
Interventions
Rationale
Palpate bladder. Investigate reports of discomfort, fullness, inability to void
Provide routine voiding measures like privacy, normal positioning, running water in sink, pouring warm water over abdomen
Perception of bladder fullness, distention of bladder above symphysis pubis indicates urinary retention Promotes relaxation urinary muscles and may facilitate voiding efforts
Evaluation
After 8 hours of nursing interventions, patient voided regularly and without difficulty. Goal met
Nursing Care Plan
Assessment
Subjective: “Anu kaya ‘tong sakit ko, san ko nakuha to?” as verbalized Objective: Restlessness noted Irritability noted Confused look Statement of misconception Development of preventable complications Frequent questions
Diagnosis
Knowledge deficit regarding condition, prognosis, treatment and discharge needs r/t information misinterpretation as evidenced by restlessness, irritability, confused look, statement of misconception, development of preventable complications and frequent questions
Planning
After 8 hours of nursing interventions, patient will verbalize understanding of disease process, prognosis, potential complications and identify necessary lifestyle changes and participate in care.
Interventions
Review disease process/prognosis and future expectations Stress importance of avoiding alcohol. Give information about community services available to aid in alcohol rehabilitation if indicated. Emphasize the importance of good nutrition. Recommendavoida nce of highprotein/salty foods, onions, and strongcheeses. Provide written dietary instructions
Rationale
Provides knowledge base from which patient can make informed choices Alcohol is the leading cause in the development of cirrhosis
Proper dietary maintenance and avoidance of foods highin sodium and protein aid in remission of symptoms andhelp prevent ammonia buildup and further liver damage.Written instructions are helpful for patient to refer to at home
Evaluation
After 8 hours of nursing interventions, patient verbalized understanding of disease process, prognosis, potential complications and identified necessary lifestyle changes and participate in care. Goal met
Nursing Care Plan
Assessment
Subjective: “Hirap ako makatulog” as claimed Objective: Sunken eyeballs Fatigue Mood alterations Agitated Body weakness noted Lethargic
Diagnosis
Disturbed sleep pattern r/t changes in activity pattern secondary to psychologic stress as evidenced by sunken eyeballs, fatigue, mood alterations, agitation, body weakness, lethargy
Planning
After 4 hours of nursing interventions, patient will establish adequate sleep pattern and report rested.
Interventions
Rationale
Evaluate level of stress
Advise to reduce fluid intake at night
Provide soft music or “white noise” if available
Increasing confusion, disorientation, and uncooperative behavior may interfere with attaining restful sleep Decreases need to get up to go to bathroom during sleep Reduces sensory stimulation by blocking out other environmental sounds that could interfere with restful sleep
Evaluation
After 4 hours of nursing interventions, patient established adequate sleep pattern and reported rested. Goal met
