Religion:Income (Monthly):Registration Number:Name of Hospital:Ward:Bed Number:Date of Admission:Diagnosis:Name of Operation:Date of Operation:Name of Doctor:Duration:Date of data collection:

B. Definition of Disease:

C. Chief Complaints of the Patient

D. Nursing Assessment of the Patient

E. Possible Nursing Diagnosis

F. Priority Needs of the Patient

NURSING DIAGNOSIS(DIAGNOSTIC OPERATIONS)OUTCOME AND PLAN(PRESCRIPTIVE OPERATIONS)IMPLEMENTATION(CONTROL OPERATIONS)EVALUATION(REGULATORY OPERATIONS)

Inability to maintain the ideal nutrition related to inadequate intake and knowledge deficit

Improved nutrition

Maintenance of a balanced diet with adequate iron supplementation.

PATIENT ASSESSMENTA. Profile of the patient Name :Age:Sex:Address:Qualification:Occupation:Marital Status:Religion:Income (Monthly):Registration Number:Name of Hospital:Ward:Bed Number:Date of Admission:Diagnosis:Name of Operation:Date of Operation:Name of Doctor:Duration:Date of data collection:

B. Definition of Disease:

C. Chief Complaints of the Patient

D. Nursing Assessment of the Patient

E. Possible Nursing Diagnosis

F. Priority Needs of the Patient

NURSING ASSESSMENTNURSINGDIAGNOSISNURSINGGOALSINTERVENTIONSRATIONALEEVALUATION

Subjective: Napansin ko na lumalaki ang tiyan ko as verbalizedObjective: Pallor Weak in appearance Jaundice Abdominal distention noted Bipedal edema Irritability noted DOB with RR of 29 bpmAbdominal girth of 32

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

After 6 hours of nursing interventions, patient will demonstrate stabilized fluid volume and decreased edema and abdominal girth. 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

Administermedications as indicated: Diuretics Potassium

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 extra vascular spaces.

After 6 hours of nsg. interventions, the patient demonstrated stabilized fluid volume and decreased edema and abdominal girth.

Goal met.

NURSING ASSESSMENTNURSINGDIAGNOSISNURSINGGOALSINTERVENTIONSRATIONALEEVALUATION

Assist with paracentesis procedure

Fluid restriction may be necessary to prevent dilutional hyponatremia

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 ASSESSMENTNURSINGDIAGNOSISNURSINGGOALSINTERVENTIONSRATIONALEEVALUATION

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

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 distentionAfter 5 hrs of nursing Interventions, patients appetite will improve from 2 tbsp to at least 5 tbsp per meal. Monitor vital signs

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

Restrict intake of caffeine, gas-producing or spicy and excessively hot or cold foods

For baseline data

A clean mouth enhances appetite To appeal to client likes and dislikes

To stimulate the appetite

May have negative effect on appetite

To stimulate the appetite

Poor tolerance to larger meals may be due to increased intra-abdominal pressure/ascites Aids in reducing gastric irritation & abdominal discomfort that may impair oral intake/digestion

After 8 hours of nursing interventions, patients appetite improved from 2 tbsp to 5 tbsp per meal.

Goal met.

NURSING ASSESSMENTNURSINGDIAGNOSISNURSINGGOALSINTERVENTIONSRATIONALEEVALUATION

Subjective:Sumasakit ang tiyan ko as verbalized with a pain scale of 6 out of 10 where in:0 - no pain1 2 mild pain3 4 moderate pain5 6 severe pain7 8 very severe pain9 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)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 6/10After 2 hours of nursing interventions, pain will be lessened with a scale of 1-10, from 6/10 to 1/10. Monitor Vital signs Perform pain assessment (COLDSPA) every time pain occurs

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 vital signs To rule out development of complications by knowing alleviating and precipitating factors Pain is subjective & cant be assessed through observation alone.

Promotes relaxation and diverts attention from pain To prove non-pharmacological management

To alleviate pain

Noisy environment stimulates irritation. After 2 hours of nursing interventions, patient was relieved from pain

Goal met.

NURSING ASSESSMENTNURSINGDIAGNOSISNURSINGGOALSINTERVENTIONSRATIONALEEVALUATION

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

Altered breathing pattern r/t decreased lung expansion secondary to intra-abdominal fluid collection (ascites) as manifested by dyspnea, tachypnea with RR of 30, irregular and shallow, weak in appearance, anxiety, irritability, restlessness, lethargy and pallor After 6 hours of nursing interventions, patient will be relieved from dyspnea and breathing pattern will return to normal. Monitor V/S Monitor respiratory rate, rhythm and depth

Auscultate breath sounds, noting crackles, wheezes and rhonchi Investigate changes in LOC

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/dyspnea 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

After 6 hours of nsg. interventions, patient was relieved from dyspnea and breathing pattern returned to normal

Goal met.

NURSING ASSESSMENTNURSINGDIAGNOSISNURSINGGOALSINTERVENTIONSRATIONALEEVALUATION

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 pts 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/Assist the patient while doing ADL Give the patient information that provides evidence progress Encourage client to do whatever possible e.g. self-care

Provide cooperative baseline To prevent over exertion

Enhances activity tolerance

Helps minimize waste of energy

Protect patient from injury

To sustain pts 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 ASSESSMENTNURSINGDIAGNOSISNURSINGGOALSINTERVENTIONSRATIONALEEVALUATION

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 Disturbed body image r/t altered physical appearance as evidenced by anxiety, fear, irritability, restlessness, feeling of helplessness and negative feelings about the body After 8 hours of nursing interventions, patient will verbalize understanding of changes and acceptance of self in the present situation.

Discuss situation/encourage verbalization of fears and concerns. Explain relationship between nature of diseaseand symptoms.

Support and encourage patient; provide care with a positive, friendly attitude

Encourage family to verbalize feelings, visit freely/participate in care Patient is very sensitive to body changes and may also experience feelings of guilt when cause is related toalcohol (70%) or other drug use. Caregivers sometimes allow judgmental feelings to affectthe care of patient and need to make every effort to helppatient feel valued as a person. Family members may feel guilty about patients conditionand may be fearful of impending death.

After 8 hours of nursing interventions, patient verbalized understanding of changes and acceptance of self in the present situation.

Goal met

NURSING ASSESSMENTNURSINGDIAGNOSISNURSINGGOALSINTERVENTIONSRATIONALEEVALUATION

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/technique 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/techniques to prevent skin breakdown.

Goal met