Nursing Care Plan for Liver Cirrhosis NCP

7/25/2019 Nursing Care Plan for Liver Cirrhosis NCP

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Student Nurses Community

NURSING CARE PLAN Liver Cirrhosis

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE:

Napansin ko nalumalaki ang tiyan koas verali!e" y t#epatient$

%BJECTIVE: &allor

'eak in

appearan(e Jaun"i(e

)"ominal

"istention note" Bipe"al e"ema

Irritaility note" *%B +it# ,, o- ./

pm )"ominal girt# o-

0.

1lui" volume

e2(ess r3t(ompromise"regulatoryme(#anismse(on"ary to(irr#osis o- t#eliver as mani-este"y pallor4 +eak inappearan(e45aun"i(e4a"ominal"istention4 e"ema4irritaility4 *%B+it# ,, o- ./ an"a"ominal girt# o-0.

)-ter 6 #ours o-

nursinginterventions4patient +ill"emonstratestaili!e" 7ui"volume an""e(rease"e"ema an"a"ominal girt#$

8onitor vital sign

8easure intake an"output

8onitor B&

)ssess respiratory

status 8onitor a"ominal

girt# &rovi"e o((asional

i(e (#ips i- N&% ,estri(t so"ium an"

7ui"s as or"ere" )"minister

me"i(ations asin"i(ate":

*iureti(s &otassium

)ssist +it#

para(entesispro(e"ure

Estalis#e" aseline "ata

,e7e(ts (ir(ulatingvolume status4"eveloping 7ui" s#i-ts4an" in response tot#erapy

B& elevations are usually

asso(iate" +it# 7ui"volume e2(ess

In"i(ative o- pulmonary

(ongestion3e"ema ,e7e(ts a((umulation o-

7ui" 9as(ites *e(reases sensation o-

t#irst4 espe(ially +#en

7ui" intake is restri(te" So"ium may e restri(te"

to minimi!e 7ui"retention in e2travas(ularspa(es$ 1lui" restri(tionmay e ne(essary toprevent "ilutional#yponatremia

Use" +it# (aution to

(ontrol e"ema an"as(ites4 lo(k e;e(t o-al"osterone4 an" in(rease+ater e2(retion +#ilesparing potassium

Serum an" (ellularpotassium are usually

)-ter 6

#ours o- nsg$interventions4t#e patient"emonstrate"staili!e" 7ui"volume an""e(rease"e"ema an"a"ominalgirt#$


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"eplete" e(ause o- liver"isease

*one to remove as(ites

7ui"
http://nursingcrib.com/http://nursingcrib.com/http://nursingcrib.com/


3/14


Nursing Care Plan

Assessment Diagnosis Planning Interventions Rationale Evaluation

Su5e(tive: 'ala akongganang kumain asverali!e"

%5e(tive: 'eak in

appearan(e ,e-usal to eat

Irritaility note"

&oor mus(le tone

Jaun"i(e note"

Ema(iate"

)"ominal"istention note"

&allor note"

Imalan(e

nutrition: less t#ano"y re=uirementsr3t loss o- appetitese(on"ary toas(ites asevi"en(e" yre-usal to eat4+eak inappearan(e4irritaility4 poormus(le tone4

ema(iate" an"a"ominal"istention

)-ter > #rs o-

nsg$Interventions4patient?sappetite +illimprove -rom .tsp to at least >tsp per meal$

8onitor vital signs

)ssist in oral #ygiene

e-ore meals$ *is(uss eating #aits

in(lu"ing -oo"pre-eren(es$

Serve -avorite -oo"s

t#at are not(ontrain"i(ate"$

&revent or minimi!e

unpleasant o"ors

"uring meal time$ Serve -oo"s t#at are

attra(tive an"palatale$

,e(ommen" small4

-re=uent meals ,estri(t intake o-

(a;eine4 gas@pro"u(ing or spi(y an"e2(essively #ot or (ol"-oo"s

&rovi"e assistan(e

+it# a(tivities asnee"e"$ &romoteun"isture" restperio"s4 espe(ially

1or aseline "ata

) (lean mout#

en#an(es appetite To appeal to (lient

likes an" "islikes To stimulate t#e

appetite 8ay #ave

negative e;e(t onappetite

To stimulate t#e

appetite &oor toleran(e to

larger meals maye "ue toin(rease" intra@a"ominalpressure3as(ites

)i"s in re"u(ing

gastri( irritation Aa"ominal"is(om-ort t#atmay impair oralintake3"igestion

Conserving energy

re"u(es metaoli("eman"s on t#eliver an" promotes

)-ter #ours o-

nursinginterventions4patient?s appetiteimprove" -rom .tsp to > tsp permeal$


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e-ore meals )"vise to (onsume

nutritious -oo"s

(ellularregeneration$


5/14


Nursing Care Plan


Su5e(tive:Sumasakit ang tiyanko as verali!e" +it# apain s(ale o- 6 out o- D+#ere in:D @ no pain . mil" pain0 F mo"erate pain> 6 severe painG very severe pain/ D +orst possile

%5e(tive: 1a(ial grima(e

note" Irritaility note"

,estlessness note"

)n2iety note"

1atigue"

Clen(#e" Hst

Beaten look

)gitation note"

&allor


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Nursing Care Plan


SUBJECTIVE: Na#i#irapan

akong #uminga asverali!e"

%BJECTIVE: *yspnea

Ta(#ypnea +it# ,,

o- 0D4 irregular4s#allo+

'eak in

appearan(e )n2iety note"

Irritaility note"

,estlessness note"

et#argi(

&allor

)ltere" reat#ingpattern r3t"e(rease" lunge2pansionse(on"ary to intra@a"ominal 7ui"(olle(tion 9as(itesas mani-este" y"yspnea4ta(#ypnea +it# ,,o- 0D4 irregular an"s#allo+4 +eak inappearan(e4an2iety4 irritaility4

restlessness4let#argy an" pallor

)-ter 6 #ours o-nursinginterventions4patient +ill erelieve" -rom"yspnea an"reat#ing pattern+ill return tonormal$

8onitor V3S 8onitor respiratory

rate4 r#yt#m an""ept#

)us(ultate reat#

soun"s4 noting(ra(kles4 +#ee!esan" r#on(#i

Investigate

(#anges in %C eep #ea" o- e"

elevate"$ &ositionon si"es

En(ourage

-re=uentrepositioning an""eep@reat#inge2er(ises

&rovi"e

supplemental %.as in"i(ate"

1or aseline "ata ,api" s#allo+

respirations3"yspnea may e presente(ause o- #ypo2iaor 7ui"a((umulation int#e a"omen

In"i(ates

"eveloping(ompli(ations an"in(reasing risk o-in-e(tion

C#anges in

mentation mayre7e(t #ypo2emiaan" respiratory-ailure

1a(ilitates

reat#ing yre"u(ing pressureon t#e "iap#ragm

)i"s in lung

e2pansion an"moili!ingse(retions

8ay e ne(essary

to treat3prevent#ypo2ia

)-ter 6 #ours o-nsg$ interventions4patient +asrelieve" -rom"yspnea an"reat#ing patternreturne" to normal


7/14


Nursing Care Plan


SUBJECTIVE: Nang#i#ina na

ako4 ayoko namag@gagala+ asverali!e"

%BJECTIVE: &allor

Bo"y malaise

note" *iap#oresis

Inaility to

(on(entrate Inaility to per-orm

usual )*s 'eak in

appearan(e imite" ,%8

*iK(ulty initiating

movements

)(tivity intoleran(e

r3t generali!e"o"y +eaknessse(on"ary toprogressive"isease state asmani-este" ypallor4 o"ymalaise4

"iap#oresis4inaility to(on(entrate4inaility to per-ormusual )*s4 +eakin appearan(e4limite" ,%8 an""iK(ulty initiatingmovements

)-ter #ours o-

nursinginterventions4patient +illparti(ipate+illingly inne(essary a(tivity4+ill learn #o+ to(onserve energy

an" verali!e relie--rom -atigue$

Evaluate pt?s

(urrent a(tivitytoleran(e

)"5ust a(tivity an"

re"u(e intensity o-task t#at may(ause un"esire"p#ysiologi(al(#anges

In(rease e2er(isean" a(tivity levelsgra"ually

Tea(# met#o"s to

(onserve energysu(# as sittingt#an stan"ing+#ile "ressing

*emonstrate3)ssis

t t#e patient +#ile"oing )*


8/14


"o +#ateverpossile e$g$ sel-@(are


9/14


Nursing Care Plan


SUBJECTIVE: 8a+a+ala a pa

Mtong laki ng tiyanko as verali!e"

%BJECTIVE: )n2iety note"

1ear o- re5e(tion

Irritaility note"

,estlessness note"

1eeling o-

#elplessness Negative -eelings

aout o"y

*isture" o"yimage r3t altere"p#ysi(alappearan(e asevi"en(e" yan2iety4 -ear4irritaility4restlessness4-eeling o-#elplessness an"negative -eelingsaout t#e o"y

)-ter #ours o-nursinginterventions4patient +illverali!eun"erstan"ing o-(#anges an"a((eptan(e o- sel-in t#e presentsituation$

*is(usssituation3en(ourage verali!ation o--ears an"(on(erns$ E2plainrelations#ipet+een nature o-"iseasean" symptoms$

Support an"

en(ourage patientOprovi"e (are +it# apositive4 -rien"ly

attitu"e

En(ourage -amily

to verali!e-eelings4 visit-reely3parti(ipatein (are

&atient is verysensitive to o"y(#anges an" mayalso e2perien(e-eelings o- guilt+#en (ause isrelate" toal(o#ol 9GDP orot#er "rug use$

Caregivers

sometimes allo+5u"gmental-eelings to a;e(tt#e (are o- patient

an" nee" to makeevery e;ort to #elppatient -eel value"as a person$

1amily memers

may -eel guiltyaout patient?s(on"itionan" may e -ear-ulo- impen"ing "eat#$

T#ey nee"non5u"gmentalemotional supportan" -ree a((ess topatient$

&arti(ipation in (are#elps t#em -eel

)-ter #ours o-nursinginterventions4patient verali!e"un"erstan"ing o-(#anges an"a((eptan(e o- sel-in t#e presentsituation$


10/14


use-ul an"promotes trustet+een sta;4patient$

Nursing Care Plan



11/14


Su5e(tive: agi akong

nangangati atparang ma#ap"ialat ko as

(laime"

%5e(tive: &ruritus note"

*ry skin

Eryt#ema note"

S(aly skin

,isk -or impaire"

skin integrity r3taltere" (ir(ulationse(on"ary toa((umulation o-

ile salts asevi"en(e" ypruritus4 eryt#ema4"ry an" s(aly skin

)-ter G #ours o-

nursinginterventions4patient +illmaintain skin

integrity an"i"enti-y in"ivi"ualrisk -a(tors an""emonstratee#aviors3te(#ni=ue to prevent skinreak"o+n$

Inspe(t skin

sur-a(e3pressurepoints routinely$


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Nursing Care Plan


Su5e(tive: Na#iirapan akong

umi#i asverali!e"

%5e(tive: )n2iety note"

Irritaility note"

,estlessness note"

Small4 -re=uent

voi"ing 1a(ial grima(e

note" uponurination

E2(essive

"iap#oresis +#entrying to voi"

Urgen(y

Impaire" urinary

elimination r3tla""er "istentionse(on"ary toas(ites asevi"en(e" yan2iety4 irritaility4restlessness4 smallan" -re=uentvoi"ing4 -a(ialgrima(e uponurination4

e2(essive"iap#oresis +#entrying to voi"4 an"urgen(y

)-ter #ours o-

nursinginterventions4patient +ill emptyla""er regularly+it# "e(rease painan" "iK(ulty$

&alpate la""er$

Investigate reportso- "is(om-ort4-ullness4 inaility tovoi"

&rovi"e routine

voi"ing measureslike priva(y4normal positioning4running +ater in

sink4 pouring +arm+ater overa"omen

&er(eption o-

la""er -ullness4"istention o-la""er aovesymp#ysis puisin"i(ates urinaryretention

&romotes

rela2ation urinarymus(les an" may-a(ilitate voi"inge;orts

)-ter #ours o-

nursinginterventions4patient voi"e"regularly an"+it#out "iK(ulty$


13/14


Nursing Care Plan


Su5e(tive: )nu kaya Mtong

sakit ko4 san konaku#a to asverali!e"

%5e(tive: ,estlessness note"

Irritaility note"

Con-use" look

Statement o-

mis(on(eption

*evelopment o-preventale(ompli(ations

1re=uent =uestions

no+le"ge "eH(it

regar"ing(on"ition4prognosis4treatment an""is(#arge nee"s r3tin-ormationmisinterpretationas evi"en(e" yrestlessness4irritaility4(on-use" look4

statement o-mis(on(eption4"evelopment o-preventale(ompli(ations an"-re=uent =uestions

)-ter #ours o-

nursinginterventions4patient +illverali!eun"erstan"ing o-"isease pro(ess4prognosis4potential(ompli(ations an"i"enti-y ne(essaryli-estyle (#anges

an" parti(ipate in(are$

,evie+ "isease

pro(ess3prognosisan" -uturee2pe(tations

Stress importan(e

o- avoi"ing al(o#ol$


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Nursing Care Plan


Su5e(tive: Lirap ako

makatulog as(laime"

%5e(tive: Sunken eyealls

1atigue

8oo" alterations

)gitate"

Bo"y +eakness

note"

et#argi(

*isture" sleep

pattern r3t (#angesin a(tivity patternse(on"ary topsy(#ologi( stressas evi"en(e" ysunken eyealls4-atigue4 moo"alterations4agitation4 o"y+eakness4 let#argy

)-ter F #ours o-

nursinginterventions4patient +illestalis# a"e=uatesleep pattern an"report reste"$

Evaluate level o-

stress

)"vise to re"u(e

7ui" intake atnig#t

&rovi"e so-t musi(

or +#ite noise i-

availale

In(reasing

(on-usion4"isorientation4 an"un(ooperativee#avior mayinter-ere +it#attaining rest-ulsleep

*e(reases nee" to

get up to go toat#room "uringsleep

,e"u(es sensory

stimulation ylo(king out ot#erenvironmentalsoun"s t#at (oul"inter-ere +it# rest-ulsleep

)-ter F #ours o-

nursinginterventions4patient estalis#e"a"e=uate sleeppattern an"reporte" reste"$

Nursing Care Plan for Liver Cirrhosis NCP

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