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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


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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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"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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"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

ncp 5 pcs

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