liver cirrhosis- ncp

NURSING CARE PLAN

PROBLEM: Edema and ascitesNURSING DIAGNOSIS: Fluid Volume Excess related to ascites and edema formationCAUSE ANALYSIS: Cirrhosis affects water and salt regulation due to portal hypertension, hypoalbuminemia, and hyperaldosteronism. Signs of fluid volume overload and portal hypertension may develop: ascites, peripheral edema, internal hemorrhoids and varices, and prominent abdominal wall veins. (Medical-Surgical Nursing. Vol. 1. 3 rd edition. by Lemone and Burk. pg. 594)

CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: “Punga ako tiyan” as verbalized by the patient.

Objectives:

Weight (April 18, 2010)- 130 lb;Weight (April 19, 2010)- 137 lbs; weight gain- 7 lbs

Urine Output (April 19,2010)- 50 ml

Pitting edema on the lower and upper extremities- grade 3 Abdominal girth- 47.1 inches

(+) Crackles

Bounding pulse.

STO:

Within 30 minutes of nursing interventions, the patient will verbalized understanding on proper food selection like low sodium diet.

LTO:

Within 8 hours of giving nursing interventions, the patient will be able to perceive the reason for fluid restriction and will be able to follow orders appropriately.

INDEPENDENT:

1. Assess for jugular vein distention, measure abdominal girth daily, and check for peripheral edema.

2. Assess urine specific gravity.

3. Provide a low-sodium diet (500 to 2000 mg/day) and restrict fluids as ordered.

4. Record intake and output every 1 to 8 hours depending on response to interventions and on patient acuity.

5. Instruct pt. to elevate the extremites affected.

DEPENDENT:

Administer diuretics, Albumin, Aldacton, Furosemide (Lasix)

1. Careful assessment is important to detect fluid shifts.

2. Specific gravity measures the concentration of urine, an indicator of hydration.

3. Excess sodium leads to water retention, and can increase fluid volume, ascites, and portal hypertension.

4. Indicates effectiveness of treatment and adequacy of fluid intake.

5. This is to reduce swelling.

Promotes excretion of fluid through the kidneys and maintenance of normal fluid and electrolyte balance.

STO:

After 30 minutes of nursing interventions, the patient verbalized understanding on proper food selection like low sodium diet.

LTO:

After 8 hours of giving nursing interventions, the patient was able to perceive the reason for fluid restriction and will be able to follow orders appropriately.

REFERENCES: Medical-Surgical Nursing. Vol. 1. 3rd ed. by Lemone and Burk. pg. 594Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Vol. 2, 10th ed. By Smeltzer and Bare. pg. 1109

NURSING CARE PLAN

PROBLEM: Risk for InjuryNURSING DIAGNOSIS: Risk for injury: Bleeding r/t disease process and destruction of Kupffer cellsCAUSE ANALYSIS: Impaired coagulation, esophageal varices and possible gastritis place the client with cirrhosis at significant risk for hemorrhage. Clotting is altered by vitamin K deficiency, impaired manufacture of coagulation factors II, VII, IX, and X, and increased platelet destruction due to splenomegaly. Also, this is due to destruction of Kupffer cells that are unable to perform phagocytosis thus, colonic bacteria enter he systemic circulation. (Medical-Surgical Nursing. Vol. 1. 3rd edition. by Lemone and Burk. page 594-595)


Subjective: “Naa lage bun-og ako kamot”, as verbalized by the patient

Objectives:

-Bruises on both upper extremities-WBC: 8-12, increased (Urinalysis, April 17, 2010)-PROTHROMBINE TIME :April 18, 2010Patient -54.1 secControl – 14.0 sec

STO: Within eight hours of rendering health teaching the patient can identify risk factors and interventions to reduce potential for infection such as maintaining aseptic technique.

LTO: Within 2 days of effective nursing intervention, the pt. would maintain/demonstrate improvement in laboratory values such as absence of WBC in the urine and blood.

INDEPENDENT:

1. Monitor vital signs; report tachycardia or hypotension.

2. Institute bleeding precautions.

3. Monitor coagulation studies and platelet count. Report abnormal results.

4. Carefully monitor the client who has had bleeding esophageal varices for evidence of rebleeding: hematemasis, hematochezia (bright blood in the stool) or tarry stools, signs of hypovolemic shock.

5. Visitors and health care workers with active infection are to avoid contact with patient.

Collaborative:

1. Administer Vitamin K

1. Increase pulse and decreasing blood pressure may indicate hypovolemia due to hemorrhage.

2. Preventive measures can decrease the risk for active bleeding.

3. Coagulation studies help determine the risk for bleeding and the nee for treatment.

4. Rebleeding is common is common following variceal hemorrhage, especially within the first week.

5. Reduced contact to infection.

1. To prevent hemorrhage

After 8 hours of rendering health teaching the patient was able to identify risk factors and interventions to reduce potential for infection such as maintaining aseptic technique.

After 2 days of effective nursing intervention, the pt. was not able to maintain/demonstrate improvement in laboratory values such as absence of WBC in the urine and blood.

REFERENCES: Medical-Surgical Nursing. Vol. 1. 3rd edition. by Lemone and Burk. pg. 594Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Vol. 2, 10th ed. By Smeltzer and Bare. pg. 1110

NURSING CARE PLAN

PROBLEM: ItchingNURSING DIAGNOSIS: Risk for impaired Skin Integrity related to pruritus from jaundice and edemaCAUSE ANALYSIS: Severe jaundice with bile salt deposits on the skin may cause pruritus. Scratching related to the pruritus damages the skin and impairs skin integrity. Malnutrition, particularly protein deficiency, and edema also increase the risk for tissue breakdown and impaired skin integrity. (Medical-Surgical Nursing. Vol. 1. 3 rd edition. by Lemone and Burk. pg. 595)


Subjective: “ Katol kaayo ako panit’, as verbalized by the patient

Objectives: -rash-reddening of skin-single firm lesions-scaling

STO:Within 8 hours of nursing care, the patient was able to regain integrity of skin surface by application of measures in minimizing skin itching.

LTO:Within 3 days of nursing care, the patient will be able to describe measures to protect the skin. Such as avoiding to harsh skin care products, clean hands, well trimmed nails.

INDEPENDENT:

1. Use warm water rather than hot water when bathing.

2. Use measures to prevent dry skin: Apply an emollient or lubricant as needed to keep skin moist, avoid soap or preparations with alcohol, and do not rub the skin.

3. If indicated, apply mittens to the hands to prevent scratching.

4. Institute measures to prevent skin and tissue breakdown: Turn at least every 2 hours, use an alternating pressure mattress, and frequently assess skin condition.

DEPENDENT:

1. Apply calamine lotion

1. Hot water increases pruritus.

2. Dry skin contributes to pruritus.

3. Clients with encephalopathy may not understand the need to refrain from scratching.

4. Frequent position changes relieve pressure and promote circulation and tissue oxygenation.

1. To decrease the itchiness of the skin.

After 8 hours of nursing care, the patient was not able to regain integrity application of measures in minimizing skin itching.

After 3 days of nursing care, the patient was not able to described measures to protect the skin. Such as avoiding to harsh skin care products.


NURSING CARE PLAN

PROBLEM: AnorexiaNURSING DIAGNOSIS: Imbalanced Nutrition: Less than Body Requirements related to abdominal fullness and discomfort and anorexiaCAUSE ANALYSIS: The client with cirrhosis is at risk for malnutrition for a number of reasons: possible chronic alcohol use, anorexia, impaired vitamin and mineral absorption and impaired protein metabolism. (Medical-Surgical Nursing. Vol. 1. 3rd edition. by Lemone and Burk. pg. 595


Subjective: “ Dili siya ganahan mukaon” as verbalized by the SO.

Objectives:

1/3 of food served consumed (April 18 & 19, 2010)

Decreased muscle tone

Appears weak

Muscle grade- 2

STO:

Within eight hours of initiating nursing interventions patient will be able to demonstrate increase appetite as evidence by consuming enough diet as indicated.

LTO:

Within three days of initiating nursing interventions patient will be able demonstrate behaviors/lifestyle changes to regain or maintain appropriate weight.

INDEPENDENT:

1. Weigh daily. Instruct to weigh at least weekly at home.

2. Provide small meals with between meal snacks.

3. Unless protein is restricted due to impending hepatic encephalopathy, promote protein and nutrient intake by providing nutritional supplements such as Ensure or Instant Breakfast.

4. Arrange for consultation with a dietitian for diet planning while hospitalized at home.

5. Provide oral hygiene.

Collaborative:

1. Administer multivitamins such as: Essentiale forte

1. Weight is a good indicator of both nutritional status and fluid balance. Short-term weight fluctuations tend to reflect fluid balance, while longer-term changes in weight are more reflective of nutritional status.

2. A small meal is more appealing for an anorexic client. Between-meal snacks help maintain adeuate calorie and nutrient intake.

3. The sodium and protein content of all meals and snacks must be calculated when maintaining restrictions of these nutrients.

4. The dietitian can provide detailed instructions, sample menus, and suggestions for improving the palatability of the dient and promoting intake.

Regulates membrane permeability and improves the exchange of substances between the intra- and extracellular space. It activates metabolic function and supports the energy balance of the liver. It restores enzyme functions and promotes detoxification of the liver. Neutral fats and cholesterol are transformed into transportable forms and led to their physiological oxidation. Liver cell regeneration is stimulated and the bile is stabilized.

STO:

After eight hours of initiating nursing interventions patient, was able to demonstrate increase appetite as evidence by consuming enough fitting diet as indicated.

LTO:

After three days of initiating nursing interventions, patient was able to demonstrate behaviors/lifestyle changes to regain or maintain appropriate weight.

Aminoleban

Mitodex (Godex)

Because of their peculiar role in whole-body nitrogen metabolism and the competitive action on amino acid transport across the blood–brain barrier, branched-chain amino acids (BCAAs) have been extensively used in subjects with liver disease to preserve or to restore muscle mass and to improve hepatic encephalopathy.

GODEX is a multicomponent drug containing Carnitine orotate, adenine HCl, cyanocobalamin, pyridoxine HCl, and riboflavin which acts synergistically. GODEX: 1.prevents fat accumulation and protects cell membrane integrity. 2. provides efficient mitochondrial energy system. 3. detoxifies acyl groups and ROS. 4.restores elctron balance for greater energy supply. 5. increases nucleic acid synthesis and mtDNA copy number for repair of mitochondria


NURSING CARE PLAN

PROBLEM: Body MalaiseNURSING DIAGNOSIS: Activity Intolerance related to fatigue, lethargy and malaise secondary to liver cirrhosis. CAUSE ANALYSIS: Due to bile salts accumulation in the blood, the decreased bile salts enable to diminished fat emulsification and absorption leading to weight loss and general weakness. Decrease in strength in muscles in any part of the body can lead to immobilization. Decreased in strength may be due to inefficient circulation of blood to a part of the body. [Medical Surgical Nursing By Smeltzer and Bare]


Subjective: “ kahoy kaayo ako lawas”, as verbalized by the patient.

Objectives: the patient

appears weak minimized

movements have limited

ROM activity needs

assistance in positioning in bed

unable to ambulate without assistance

stays in bed most of the time

STO: Within 4 hours of effective nursing intervention the patient will regain normal mobility as evidenced by ability to move within the physical environment

LTO: Within 8 hour shift, the patient will maintain/increase strength and function of affected or compensatory body parts as evidenced by coordination, normal ROM, and increased muscle strength.

INDEPENDENT:

1. Asses level of activity tolerance and egree of fatigue, lethargy and malaise when performing routine ADLs.

2. Assist with activities and hygiene when fatigued.

3. Encourage rest when fatigued or when abdominal pain or discomfort occurs.

4. Assist with selection and pacing of desired activities and exercise.

5. Provide diet high in carbohydrates with protein intake consistent with liver function.

DEPENDENT:

1. Administer suplemental vitamins (A, B complex, C, and K).

1. Provides baseline for further assessment and criteria for assessment of effectiveness of interventions.

2. Promotes exercise and hygiene within patient’s level of tolerance.

3. Conserves energy and protects the liver.

4. Stimulates patient’s interest in selected activities.

5. Provides calories for energy and protein for healing.

1. To provides additional nutrients.

STO: After 4 hours of effective nursing intervention the patient was not able to regain normal mobility as evidenced by ability to move within the physical environment

LTO: After 8 hour shift, the patient was not able to maintain/increase strength and function of affected or compensatory body parts as evidenced by coordination, normal ROM, and increased muscle strength.

REFERENCES: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Vol. 2, 10th ed. By Smeltzer and Bare. pg. 1107

NURSING CARE PLAN

PROBLEM: Edema/Ascites


Subjective: “nidako lage ako tiyan” as verbalized by the patient.

Objectives: -pitting edema grade 3-skin rashes-bruises

STO: After 2 days in giving nursing intervention, the patient will be able to verbalize acceptance of self in situation, relief of anxiety and adaptation to altered body image and will be able to verbalize understanding of body changes.

LTO: After 3 days of giving nursing intervention, the patient will be able to recognize and incorporate body image change into self concept in accurate manner without negating self esteem, and will be able to acknowledge self as an individual who has responsibility to self.

INDEPENDENT:

1. Assess changes in appearance and the meaning these changes have for patient and family.

2. Encourage patient to verbalize reactions and feelings about these changes.

3. Assess patient’s and family’s previous coping strategies.

4. Assist and encourage patient to maximize appearance and explore alternatives to previous sexual and role functions.

5. Assist patient in identifying short-term goals.

6. Encourage and assist patient in decision making about care.

7. Identify with patient resources to provide additional support (counselor, spiritual advisor).

8. Assist patient in identifying previous practices that may have been harmful to self (alcohol and drug abuse).

1. Provides information for assessing impact ofchanges in appearance, sexual function, and role on the patient and family.

2. Enables patient to identify and express concerns; encourages patient and significant others to share these concerns.

3. Permits encouragement of those coping strategies that are familiar to patient and have been effective in the past.

4. Encourages patient to continue safe roles and functions while encouraging exploration of alternatives.

5. Accomplishing these goals serves as positive reinforcement and increases self-esteem.

6. Promotes patient’s control of life and improves sense of well-being and self-esteem

7. Assists patient in identifying resources and accepting assistance from others when indicated.

8. Recognition and acknowledgment of the harmful effects of these practices are necessary for identifying a healthier lifestyle.

STO: After 2 days of giving nursing interventions the patient was able verbalized acceptance of self in situation relief anxiety and adaptation to altered body image and was able verbalized understanding of body changes.

LTO: After 3 days the patient was able to recognized and incorporated body image into self-concept in accurate manner without negating self-esteem and was able to acknowledge self as an individual who has responsibility for self.

NURSING DIAGNOSIS: Disturbed body image related to changes in appearance, sexual dysfunction, and role functionCAUSE ANALYSIS: In liver cirrhosis, increased Na and water retention causes edema due to fluid shift to extravascular compartment leading to edema. Endocrine function is also altered with increased/elevated androgen and estrogen levels in the blood of male and female, respectively. Common manifestations include gynecomastia, decreased libido, fall of body hair, atrophy of testicles in male. In female - hirsutism, acne, deepening of voice, and increase virilism. (Medical Surgical Nursing – Udan, pp. 333)

REFERENCES: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Vol. 2, 10th ed. By Smeltzer and Bare. pg. 1108-1109

NURSING CARE PLAN

PROBLEM: Abdominal PainNURSING DIAGNOSIS: Acute pain and discomfort related to enlarged tender liver and ascites and oversecretion of acid.CAUSE ANALYSIS: In liver cirrhosis, abdominal pain may be present because of recent, rapid enlargement of the liver, producing tension on the fibrous covering of the liver (Glisson’s capsule). Later in the dse the liver decreases in size as scartissue contracts the liver tissue. The liver edge is palpable, is nodular. Also, due to imapired gastrin in the blood causes excessive stimulation of the stomach parietal cells leading to oversecretion of acid. (Med-Surg Nursing by Bare, pp. 1102)


Subjective: Pt. may verbalize pain at the abdominal area.P- when respiration and movingQ-stabbingR-whole abdomenS-6/10 T- when moving felt for about 2 minute

Objectives:-restless-muscle tension present-irritable-facial grimace

STO:Within 1-2 hours of implementing nursing interventions, patient will be able to verbalize pain relief at a level of from a scale 1/10 verbalizes feelings of reasonable comfort.

LTO:Within 8 hours of effective nursing intervention, patient will be free from pain as evidenced by stable v/s, absence of muscle tension and restlessness.

INDEPENDENT:

1. Maintain bed rest when patient experiences abdominal discomfort.

2. Observe, record, and report presence and character of pain and discomfort.

3. Reduce sodium and fluid intake if prescribed.

4. Prepare patient and assist with paracentesis.

DEPENDENT:

5. Administer antispasmodic and sedative agents as prescribed.

1. Reduces metabolic demands and protects the liver.

2. Provides baseline to detect further deterioration of status and to evaluate interventions.

3. Minimizes further formation of ascites.

4. Removal of ascites fluid may decrease abdominal discomfort.

5. Reduces irritability of the gastrointestinal tract and decreases abdominal pain and discomfort.

STO:Objective partially met, patient verbalized pain scale 0f 2/10.

LTO:After 8 hours of effective nursing intervention, patient was able to be free from pain as evidenced by stable v/s, absence of muscle tension and restlessness.


NURSING CARE PLAN

PROBLEM: Difficulty of breathingNURSING DIAGNOSIS: Ineffective breathing pattern related to ascites and restriction of thoracic excursion secondary to ascites, abdominal distention, and fluid in the thoracic cavity

CAUSE ANALYSIS: In liver cirrhosis, portal hypertension causes hepatic shunting due to splenomegaly (impaired RBC destruction) causing excessive RBC lysis as evidenced by decreased RBC in the serum blood plasma which impairs oxygen and carbon dioxide exchange, thus tachypnea occurs to compensate more oxygen demand and carbon dioxide as stimulator for respiration. (Med-Surg Nursing by Carol Porth)


Subjective: “lisud kaayo iginhawa”, as verbalized by the patient.

Objectives: -flaring of nose-inadequate chest expansion-RR (23-25)-presence of adventitious sounds-crackles-use of accessory muscle-O2 sat -87-88-capillary refill- <3

STO: Within 1-2 hours of nursing interventions, patient will participate in actions to maximize oxygenation as evidenced by participating in deep-breathing exercises, coughing exercise.

LTO:Within 3 days of implementing nursing interventions, patient will be able experience maximal pulmonary ventilation and adequate gas exchange by absence of pallor, and difficulty of breathing.

INDEPENDENT:

1. Elevate head of bed to at least 30 degrees.

2. Conserve patient’s strength by providing rest periods and assisting with activities.

3. Change position every 2 hours.

DEPENDENT:

4. Assist with paracentesis

a. Explain procedure and its purpose to patient.

b. Have patient void before paracentesis.

c. Support and maintain position during procedure.

d. Record both the amount and the character of fluid aspirated.

5. Administer O2 @ 10 l/min

6. Administer Salbutamol.

1. Reduces abdominal pressure on the diaphragm and permits fuller thoracic excursion and lung expansion.

2. Reduces metabolic and oxygen requirements.

3. Promotes expansion and oxygenation of all areas of the lungs.

4. Paracentesis is performed to remove fluid from the abdominal cavities may be frightening to the patient.

a. Helps obtain patient’s cooperation with procedures.

b. Prevents inadvertent bladder injury.

c. Prevents inadvertent organ or tissue injury.

d. Provides record of fluid removed and indication of severity of limitation of lung expansion by fluid.

5.To provide adequate oxygen inhalation

6. to promote bronchodilation

STO: After 1-2 hours of nursing interventions, patient was able to participate in actions to maximize oxygenation as evidenced by participating in deep-breathing exercises, coughing exercise.

LTO:After 3 days of implementing nursing interventions, patient was not able to experience maximal pulmonary ventilation and adequate gas exchange by absence of pallor, and difficulty of breathing.


NURSING CARE PLAN

PROBLEM: Anxiety

NURSING DIAGNOSIS: Anxiety related to threat to or change in health status associated with stressCAUSE ANALYSIS: Disease is the major cause of psychological disturbances of most individual. It affects the five dimensions yet it is more on psychoaspect of the person. When the individual knows that he/she is ill the first alteration is the behavioral and followed by the psychological. From time to time the pt. become anxious and deppressed leading to contribution to body stress. Other may not sleep but others can do cope with it. Reference: General Psychology by Bustos page 35-38.


Subjective: No verbal cues

Objectives:- restlessness-increased BP- 140/100-increased HR- 95

STO:

Within 4 hrs. of rendering effective nursing interventions the pt. will be able to display decrease anxiety state as evidenced by cooperation and conversant to the health care team.

LTO:

Within 8 hrs. of rendering effective nursing care the pt. will be able to be knowledgeable enough about on how to develop good coping skills.

INDEPENDENT:

1. Monitor anxiety behavior and relationship to activity, events, people every shift.

2. Assist the pt. to learn recognizes and identifies the signs and symptoms of anxiety.

3. Provide calm, none threatening environment.

4. Attend the primary physical needs promptly.

5. Monitor the vital signs per shift.

6. Assist pt. in developing coping skills.

DEPENDENT:

1. Refer the pt. to a collaborative with appropriate community resources for care.

1. When anxiety increases, the abillity to follow instruction or cooperation in plan of care decreases. Identification of the behavior and causative factors enhances intervention plans.2. Helps identify connection between the precipitating cause and the anxiety experience.

3. Conveys calm and helps the pt. focus on conversation or activity.

4. Conserves the pt’s energy and allows the pt. to fucos on coping with and reducing anxiety. Failure to attedn physical needs promptly would serve to increase anxiety.5. Assist in determining the effects of anxiety. Helps determine pathologic effects of anxiety.6. Methods that can be used successfully to decrease anxiety. Allows the pt. to practice and become comfortable in skills with supporting environment. Determines what has helped and determines whether these measures are still useful.

DEPENDENT:

1. Support groups can provide ongoing assistance after discharge.

STO:

After 4 hrs. of rendering effective nursing interventions the pt. displayed decrease anxiety state as evidenced by cooperation and conversant to the health care team.

LTO:

After 8 hrs. of rendering effective nursing care the pt. was knowledgeable enough about on how to develop good coping skills.

REFERENCES: Clinical Applications of Nursing Diagnosis by Cox, H. et al pages 456-458

NURSING CARE PLAN

PROBLEM: Tachycardia

NURSING DIAGNOSIS: Altered Tissue Perfusion related to psychological and physical changes associated with fluctuations of peripheral pulse ratesCAUSE ANALYSIS: When the person becomes stressful and anxious the symphathetic nervous system will be stimulated thus increasing the heart rate of the individual. This stimulation is triggered by the circulating baroreceptors that activate the sympathetic nervous system to increase excitability.Reference: Medical Surgical Nursing by Ignatavicius and Workman page 929.


Subjective: No subjective cues

Objectives:

RR- 23-25 breathes per minPR- 90-95Appears weak

STO: Within 4 hrs. of rendering effective nursing interventions the pt. will be able to take resting periods to stabilized the PR and RR.

LTO:

Within 8 hrs. of rendering effective nursing care the pt. will be able to experience no signs of anxiety and fatigue.

INDEPENDENT:

1. Monitor the trends in heart rate and blood pressure.

2. Record skin temperature, color, quantity and equality of peripheral pulses.

3. Measure and document input and output.

4. Monitor daily activities. Note pt. response to its vital signs.

5. Evaluate the presence of physical stress, anxiety and fatigue. Encourage use of relaxation technique such as deep breathing.

6. Monitor output.

DEPENDENT:

1. Administer IV fluids as ordered.

1. Tachycardia is common response to discomfort and anxiety likewise with pain perceived by the pt., fluid replacement and stress.2. May indicate decrease oxygenation as a result of diminished cardiac output.

3. Useful in determining fluid needs or identifying fluid excess which compromise cardiac output and oxygenation.4. Regular activities and mobility stimulates circulation and promotes feeling of well-being.

5. Excessive emotional reaction can affect vital signs of the pt.

6. Reduced in circulatory volume which negatively affects perfusion.

1. Maintains adequate circulating volume and enhance oxygen carrying capacity.

STO: After 4 hrs. of rendering effective nursing interventions the pt. was able to take resting periods to stabilized the PR and RR.

LTO:

After 8 hrs. of rendering effective nursing care the pt. experienced signs of anxiety and fatigue

REFERENCES: Clinical Applications of Nursing Diagnosis by Cox, H. et al pages 124-125.

NURSING CARE PLAN

PROBLEM: CracklesNURSING DIAGNOSIS: Impaired Gas Exchange r/t accumulation of fluid in pleural space secondary to Liver Cirrhosis

CAUSE ANALYSIS: Accumulation of secretion in the lungs will inhibit the transport of oxygen to the cell and carbon dioxide out from the cell thus causing ventilation imbalance.( Med. Surg. Nursing by S. Smeltzer and B. Bare pp, 468-469)


Subjective:No verbal cues

Objective: Use of accessory musclesLabored breathing (shallow breathing)RR- 23-25 breathes per minO2 sat -87-88(+) crackles

Short term objective:After 8 hours of giving effective nursing intervention and health teaching, the patient will be able to know positioning techniques that improve ventilation.

Long term objective:After 3 days of giving effective nursing intervention and health teaching, the patient will demonstrate improve ventilation as evidence by blood gases within client’s normal parameters.

Independent:

1. Position client in either semi-fowlers position or side lying position

2. Encourage client to cough as tolerated.

3. Monitor respiratory rate, depth, and effort, including use of accessory muscles, nasal flaring, and thoracic or abdominal breathing.

4. Monitor client’s behavior and mental status for onset of restlessness, agitation, confusion

5. and in the late stages, extreme lethargy

6. Observe for cyanosis in skin: note especial color of tongue and oral mucous membrane.

Dependent:1. Administer oxygen

inhalation appropriately.2. Administer salbutamol

1. Promote good ventilation and breathing.

2. Will promote mucoid or sputum excretion from the lungs

3. Proper assessment will help identify early problems.

4. Changes in behavior and mental status can be early signs of impaired gas exchange

5. Central cyanosis in tongue and oral mucosa is indication of serious hypoxia and is a medical emergency;

6. Peripheral cyanosis seen in extremities may not be serious.

1. To promote enough oxygen supply

2. To provide bronchodilation.

After 8 hours of giving effective nursing intervention and health teaching, the patient was able to know positioning techniques that improve ventilation.

After 3 days of giving effective nursing intervention and health teaching, the patient was not able to demonstrate improve ventilation as evidence by blood gases within client’s normal parameters.

Reference: Nursing care Plan: Guidelines for individualizing patient car.ed6; M. Doenges, M.F Moorhouse, A. Geissler-Murr.pp.199-200

NURSING CARE PLAN

PROBLEM: Risk for AspirationNURSING DIAGNOSIS: Risk for aspiration related to the presence of nasogastric tubeCAUSE ANALYSIS: Aspiration pneumonia occurs when stomach contents or enteral feedings are regurgitated and aspirated, or when an NGT is improperly positioned and feedings are instilled into the pharynx or the trachea.(Med. Surg. Nursing by S. Smeltzer & B. Bare pp. 993-994)

CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATIONSubjective:No Verbal Cues

Objective:Appears weakUse of accessory muscleDifficulty of breathing

Short term objective:

After 2days of giving effective nursing intervention and health teaching, the patient will be able to strengthen swallowing reflex when the NGT will be removed.

Long term objective:

After the patient will be discharged, the patient will be able to swallow foods appropriately and swallowing impairment will goes back to normal.

Independent:

1. Check to make sure initial feeding tube placement was confirmed by x-ray, especially if a small bore feeding tube is used; keep feeding tube securely taped.

2. Determine placement of feeding tube before each feeding or every 4 hours if continuous feeding. Check pH of aspirate; do not rely on air insufflation method.

3. Check for gastric residual at least every 8 hours and before feedings; if greater than 100 ml, follow institutional protocol on holding feeding.

4. During feeding, position client with head of bed elevated at least 30 degrees, preferably higher; maintain for 30 to 45 minutes after feeding.

5. Stop continual feeding temporarily when turning or moving client.

6. Carefully check elderly client’s gag reflex and ability to swallow before

1. X-ray verification of placement is the only consistently reliable method to detect inadvertment respiratory placement.

2. The auscultatory air insufflation method is often not reliable in differentiating between gastric or respiratory placement. pH testing can generally predict feeding tube position in the gastrointestinal tract.

3. Increased intragastric pressure can result in regurgitation and aspiration.

4. Keeping the client’s head elevated helps keep food in stomach and decrease incidence of aspiration.

5. It is difficult to keep the head elevated when turning or moving a client.

6. Laryngeal nerve endings are reduced in the elderly, which diminishes the gag reflex.

After 2days of giving effective nursing intervention and health teaching, the patient was not able to strengthen swallowing reflex when the NGT will be removed.

After the patient will be discharged, the patient was not able to swallow foods appropriately and swallowing impairment will goes back to normal.

Reference: Nursing Diagnosis Handbook: A guide to planning care by: Auckley & Ladwig pp. 116-117

NURSING CARE PLAN

PROBLEM: Lack of informationNURSING DIAGNOSIS: Knowledge Deficit: cause/treatment of condition related to lack of factual information of disease process

CAUSE ANALYSIS: Knowledge deficit is a state which an individual or family does not comprehend, learn or demonstrate knowledge of health care measure necessary to maintain health. Having lack of information regarding the disease condition, patient cannot make effective decisions about his/her health that results to inability to participate to participate actively and assume responsibility for much of his/her own care. (Med-Surg by Brunner and Suddarth pg. 46, Fundamentals of Nursing pg. 392)


Subjective:“ Wala ko kabalo unsa hinungdan kung ngano nag ka hepa ko”, as verbalized by the patient.

Objective: patient asking questions

about her condition requests for additional

information inaccurate follow through of

instructions

STO: After 15 mins of appropriate health teachings, patient will be able to verbalize understanding of condition and potential complication, individual risk factors.

LTO: After 2 days of care, patient will correctly perform necessary procedures and explain reasons of action, actively participates in regimens given to promote wellness.

Independent:o Assess patient/SO level of

knowledge and ability/desire to learn.

o Be alert to signs of avoidance, e.g., changing subject away from information being presented or extremes of behavior (withdrawal/euphoria).

o Present information in varied learning formats, e.g., programmed books, audiovisual tapes, question-and-answer sessions, group activities.

o Reinforce explanations of risk factors, dietary/activity restrictions, medications, and symptoms requiring immediate medical attention.

o Necessary for creation of individual instruction plan. Reinforces expectation that this will be a “learning experience.” Verbalization identifies misunderstandings and allows for clarification.

o Natural defense mechanisms, such as anger or denial of significance of situation, can block learning, affecting patient’s response and ability to assimilate information. Changing to a less formal/structured style may be more effective until patient/SO is ready to accept/deal with current situation.

o Using multiple learning methods enhances retention of material.

o Provides opportunity for patient to retain information and to assume control/participate in rehabilitation program. Note: Routine use of supplements/herbal remedies (e.g., ginkgo biloba, garlic, vitamin E) can result in alterations in blood clotting, especially

After 15 mins of appropriate health teachings, patient was able to verbalize understanding of condition and potential complication, individual risk factors.

After 2 days of care, patient was not able to perform necessary procedures and explain reasons of action, actively participates in regimens given to promote wellness.

o Encourage identification/reduction of individual risk factors, e.g., smoking/alcohol consumption, obesity.

o Warn against isometric activity, Valsalva maneuver, and activities requiring arms positioned above head.

o Review programmed increases in levels of activity. Educate patient regarding gradual resumption of activities, e.g., walking, work, recreational and sexual activity. Provide guidelines for gradually increasing activity and instruction regarding target heart rate and pulse taking, as appropriate.

o Identify alternative activities for “bad weather” days, such as measured walking in house or shopping mall.

o Review signs/symptoms requiring reduction in activity and notification of healthcare provider. Differentiate between increased heart rate that normally occursduring various activities and worsening signs of cardiac stress (e.g., chest pain,

when anticoagulant/ASA therapy is prescribed.

o These behaviors/chemicals have direct adverse effects on cardiovascular function and may impede recovery, increase risk for complications.

o These activities greatly increase cardiac workload and myocardial oxygen consumption and may adversely affect myocardial contractility/output.

o Gradual increase in activity increases strength and prevents overexertion, may enhance collateral circulation, and allows return to normal lifestyle. Note: Sexual activity can be safely resumed once patient can accomplish activity equivalent to climbing two flights of stairs without adverse cardiac effects.

o Provides for continuing daily activity program.

o Pulse elevations beyond established limits, development of chest pain, or dyspnea may require changes in exercise and medication regimen.

dyspnea, palpitations, increased heart rate lasting more than 15 min after cessation of activity, excessive fatigue the following day).

o Stress importance of follow-up care, and identify community resources/support groups, e.g., cardiac rehabilitation programs, “coronary clubs,” smoking cessation clinics.

o Emphasize importance of contacting physician if chest pain, change in anginal pattern, or other symptoms recur.

o Stress importance of reporting development of fever in association with diffuse/atypical chest pain (pleural, pericardial) and joint pain.

DEPENDENTo Encourage patient/SO to

share concerns/feelings. Discuss signs of pathological depression versus transient feelings frequently associated with major life events. Recommend seeking professional help if depressed feelings persist.

o Reinforces that this is an ongoing/continuing health problem for which support/assistance is available after discharge. Note: After discharge, patients encounter limitations in physical functioning and often incur difficulty with emotional, social, and role functioning requiring ongoing support.

o Timely evaluation/intervention may prevent complications.

o Post-MI complication of pericardial inflammation (Dressler’s syndrome) requires further medical evaluation/intervention.

o Depressed patients have a greater risk of dying 6–18 mo following a heart attack. Timely intervention may be beneficial. Note: Selective serotonin reuptake inhibitors (SSRIs), e.g., paroxetine (Paxil), have been found to be as effective as tricyclic antidepressants but with significantly fewer adverse cardiac complications.

Reference: Nursing Care Plan 6th edition by Doenges, Geissler-Murr, & Moorhouse

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