Nursing Care Plan for Liver Cirrhosis NCP
Transcript of Nursing Care Plan for Liver Cirrhosis NCP
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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"
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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$
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Nursing Care Plan
Assessment Diagnosis Planning Interventions Rationale Evaluation
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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ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
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
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Nursing Care Plan
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
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 )*
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"o +#ateverpossile e$g$ sel-@(are
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Nursing Care Plan
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
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$
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use-ul an"promotes trustet+een sta;4patient$
Nursing Care Plan
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
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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
Assessment Diagnosis Planning Interventions Rationale Evaluation
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$
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Nursing Care Plan
Assessment Diagnosis Planning Interventions Rationale Evaluation
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
Assessment Diagnosis Planning Interventions Rationale Evaluation
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"$