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Assesment Diagnosis Planning Interventions Rationale Evaluation
Subjective:
Verbalized changein eating patterns
(loss o appetite!
"bjective:
#od$ malaise
Poor muscle tone
Decrease in %eight
&oss o appetite
Imbalances in
nutritional studies
'utrition:
imbalanced less
than bod$
re)uirements
related to
Inade)uate diet*
inabilit$ to
process+digest
nutrients
evidenced b$ Poor
muscle
tone+%asting
Short term:
Ater , hours onursing
intervention the
patient %ill be able
to demonstrate
behaviors+ liest$le
changes to regain
or maintain
appropriate %eight
&ong term:Ater - da$s o
nursing
intervention the
patient %ill sho%
signs o proper
appetite and
proper nutritional
status
./easure dietar$
inta0e b$ caloriecount1
.Encourage
patient to eat*
e2plain reasons or
the t$pes o diet1
3eed patient i
tiring easil$ or
have S" assistpatient1 Include
patient in meal
planning to
consider his+her
preerences in ood
choices1
.Suggest sot
oods avoidingroughage i
indicated1
.Recommend
cessation o
smo0ing1 Provide
teaching on the
.Provides
importantinormation about
inta0e needs and
de4ciencies1
.Improved
nutrition and diet is
vital to recover$1
Patient ma$ eat
better i amil$ is
involved andpreerred oods are
included as much
as possible1
.5emorrhage rom
esophageal varices
ma$ occur in
advanced cirrhosis1
.Reduces
e2cessive gastric
stimulation and ris0
o irritation and
ma$ lead to
bleeding1
Ater - da$s o
nursinginterventions the
patient has sho%n
signs o increase in
appetite decrease
in malaise and
increasing
nutritional status1
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possible negative
e6ects o smo0ing1
.Reer to dietitian
to provide diet highin calories and
simple
carboh$drates lo%
in at and
moderate to high in
protein* limit
sodium and 7uid as
necessar$1 Provide
li)uid supplements
as indicated1
.5igh8calorie oods
are desired
inasmuch as
patient inta0e isusuall$ limited1
9arboh$drates
suppl$ readil$
available energ$1
3ats are poorl$
absorbed because
o liver d$sunction
and ma$ contribute
to abdominal
discomort1
Proteins are
needed to improve
serum protein
levels to reduce
edema and to
promote liver cell
regeneration1 'ote:
Protein and oods
high in ammonia(gelatin! are
restricted i
ammonia level is
elevated or i
patient has clinical
signs o hepatic
encephalopath$1 In
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addition these
individuals ma$
tolerate vegetable
protein better than
meat protein1
Assesment Diagnosis Planning Interventions Rationale Evaluation
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"bjective:
- /elena noted
- Decreased
platelet count o ; 2
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.Cse a sot
toothbrush or a
gauze to clean the
teeth.Place the patient
at semi8o%lers
position
./ove and turn
the patient gentl$
to the sides ever$
t%o hours
.Bransuse blood
(33P! as ordered
.Administer
medications such
as vitamin as
ordered
.Administer
o2$gen as
indicated
circulating blood
volume
. Bo preventbleeding in the
gums
. Bo prevent
aspiration o blood
. Bo prevent
bleeding caused b$
s0in brea0do%n
and decubitus
ulcers
. Bo increase the
patients blood
volume
. Bo address the
condition and
continue course o
treatment
. Bo maintain
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ade)uate o2$gen
tissue perusion
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Assesment Diagnosis Planning Interventions Rationale Evaluation
"bjective:
8 Increased bod$temperature o
=,1=
- S0in is %arm to
touch- Increased
respirator$ rate
o >
-ascites
5$perthermia
related to therelease o
endogenous
p$rogen secondar$
to presence o liver
cirrhosis
@ithin m$ 8= hour
span o care m$patients bod$
temperature %ill
decrease rom
=,1F9 to =G1;8
=-1;F91
./onitor patients
vital signs1
.'ote
chronological and
developmental age
o client1
.Provide tepid
sponge bath
.&imit clothing in
light%eight loose8
4tting clothes1
.9ool the
environment %ith
air8conditioning or
ans1
. serves as
baseline data
.Elderl$ or
impaired
individuals a$ not
be able to
recognize and+or
act on s$mptoms o
h$perthermia
. promotes heat
loss b$
evaporation and
conduction
. encourages heat
loss b$ radiation
and conduction1
. promotes heat
loss b$ convection
@ithin the , hours
span o care thepatient %as able to
maintain normal
hemod$namic
status as
evidenced b$ a
normal inta0e and
output
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.eep clothing and
linens dr$1
.Administerreplacement 7uids
and electrol$tes
1
./aintain bedrest
Discuss importance
o ade)uate 7uid
inta0e
INTERDEPENDEN
T
9ollaborate %ith
dietician in
providing patient
%ith high8calorie
diet or parenteral
nutrition
. to reduce
shivering
.to replace 7uids
lost through
perspiration and
respiration1
. to reduce
metabolic
demands
. Bo prevent
deh$dration
. to meet
increased
metabolic
demands
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'oti$ ph$sician i
pharmacologic
regimen is
inade)uate tomeet
h$perthermia
control goal1
DEPENDENT
.Administer
antip$retics orall$
or rectall$ as
ordered1
.Provide
supplemental
o2$gen as ordered1
. to determine ithere is a need to
increase dosage
change medication
or use a stepped
program (e1g1
s%itching rom
injection to oral
route or
lengthening time
interval bet%een
doses!1
. to aid in reducing
the bod$
temperature
. to o6set
increased o2$gen
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.Administer
replacement IV
7uids andelectrol$tes as
ordered1
demands and
consumption1
. to support
circulating volumeand tissue
perusion and to
aid in h$dration
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"bjective:
8 ascites
8dr$ scal$ and
shin$8edema
8d$spnea
3luid Volume
E2cess in the
interstitial space
related to liverorgan ailure as
evidenced b$
ascites
@ithin , hours
span o care the
client %ill be able
to :
a Stabilize 7uid
volume as
evidenced b$
balanced I+"
Vital signs
%ithin normal
limits
./easure vital
signs
.Assess or
evidence o
dependent venous
pooling or
venostasis1
.Provide )uiet
environment
limiting e2ternal
stimuli1
./onitor inta0e
and output
.Promote re)uent
. Bo obtain
baseline date and
to note an$
unusualities
.Bo determine
causative actors
. Bo promote
ade)uate rest and
comort or aster
recover$
. Bo determine
elimination o
e2cess 7uid
. Bo reduce tissue
pressure and ris0 o
tissue injur$
@ithin the , hours
span o care the
patient %as able to
maintain normalhemod$namic
status as
evidenced b$ a
normal inta0e and
output
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position change
.Protect
edematous s0in
rom injur$1
Bo protect s0in
integrit$ and
prevent inection
./easure
abdominal girth or
changes that ma$
indicate increasing
7uid retention+
edema1
.Administer
medications
(diuretics!
.Provide )uiet
. Bo protect s0in
integrit$ and
prevent inection
.Bo evaluate
degree o e2cess
. Bo promote aster
recover$
. Bo promote rest
and sleep
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Assesment Diagnosis Planning Interventions Rationale Evaluation
"bjective:
8 Haundice notedin the s0in upon
inspection18 > pitting
edema noted
on all our
e2tremities8 (! bod$
malaiseVital Signs:
#P8 c$cles per
minute
BE/P1 K =,1= F9
Ris0 or impaired
s0in integrit$related to
prolonged bed rest
@ithin , hours
span o care thepatient %ill
maintain
undamaged
ph$sical
S0in integrit$ b$
not maniesting
signs o decubitus
ulcer1
./onitor patients
vital signs1.Assess or an$
changes in s0in1
. 'ote and record
degree o jaundice
o s0in and sclera
and scratches on
the bod$1
./aintain strict
s0in h$giene1
.Provide ade)uate
clothing+covers1
."bserve or
reddened+blanched
areas and institute
treatment
. serves as
baseline data. to be able to
determine the
causative actors
. to be able to
assess s0in
integrit$
. to prevent the
spread o bacteria
and prevent
inection
.Reduces
li0elihood o
progression to s0in
Ater , hours span
o care the patientstill maintained
intact s0in integrit$
as evidenced b$
absence o
decubitus ulcer at
the patients bac01
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immediatel$1
.9hange patients
position ever$ t%o
hours1.Drain urine bag
ever$ t%o hours1
.Encourage
re)uent s0in care
to signi4cant other1
Also perorm
morning care to
patient b$
perorming
complete bed bath
and appl$ lotion
ater%ards1
.Emphasize
importance o
ade)uate
nutritional+7uid
brea0do%n1
. Bo relieve the
pressure on the
patients bac01
. Bo monitor
output o patient in
order to determine
7uid and
electrol$te inta0e
and loses
. Bo promote
h$giene and s0in
integrit$1 Bo
promote s0in
moisture and
prevent roughness
on s0in1
. to maintain
general good
health and s0in
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inta0e to signi4cant
others1 (through
'?B eeding!
.Administermedications as
ordered1
turgor1
. to treat an$underl$ing cause