VIRAL HEPATITIS

Study
Case

Assessment Nursing Analysis Planning Interventions Rationale Evaluation

Diagnosis

Subjective cues: Acute Pain Inflammatio After 4 1.Perform a 1.To asses pain Goal met:
related to n of the liver hours of comprehensive and to scale
“Ang sakit ng After 4
inflammatio nursing assessment to pain pain from (0-
kanang bahagi ng hours of
n and intervention to include location, 10)
tyan ko”,as nursing
swelling of Activation of , the characteristics, and
verbalized by the intervention,
the liver the viscera- patient’s duration,
patient. the patient’s
receptors in pain will be frequency,severinity
pain is
Objective cues: the liver due reduced , (0-10 scale)
reduced
to from scale precipitating factors
• Guarding from scale of
inflammatio of 8 to
behavior 8 to scale of
n scale of 4 or
4
at tolerable 2.Provide comfort 2.To maintain
• With facial level pressure acceptable
grimace
level of pain
• Irritable management

• With pain
scale of Acute pain 3.Provide analgesics 3.To provide
8/10 (10 as prescribed by the pharmacologica
Being the physician l pain
most management
painful)
4.To assist
4.Encourage
client to
diversional activities
explore
methods to

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control pain

5.Encourage 5.To prevent

adequate rest fatigue
periods

6.Review ways to
6.To lessen the
lessen pain,
pain
including techniques
such as therapeutic
touch and relaxation
skills

7. Discuss ways in 7. To know the

which they can ways that can
assist client to help the client
reduced to reduced
precipitating factors precipitating
that cause or factors that can
increase pain. cause or
increase pain.

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Case

Assessment Nursing Analysis Planning Interventions Rationale Evaluation

Diagnosis

Subjective cues: Imbalanced Altered liver After four (4) 1. Assess 1.provides Goal
Nutrition: Less function weeks of weight, age, comparative partially
“Wala akong ganang than body nursing body-build, baseline met.
kumain. Iba kasi ang requirements interventions strength,
panlasa ko,” as After 4
related to loss Alteration in the patient activity/rest
verbalized by the weeks the
of appetite and the will level & so fort.
patient. patient was
inability to metabolism demonstrate
2.discuss 2.to establish able to gain
Objective cues: ingest of nutrients progressive
eating habits a nutritional weight as
adequate needed in weight gain
• Wt.= 50kg food plan that evidence by:
nutrients the body toward goal.
preferences, needs patient Previous
• Poor muscle intolerance needs wt.=50kg
tone aversion
Alteration in Latest
• Pale enzyme
conjunctiva 3.to stimulate wt.=56kg
production 3.encourage appetite
that aids in
• Restlessness client to
digestion choose foods
that are
appealing
Loss of 4.to enhance
appetite 4.Promote
food intake
pleasant,
relaxing
environment,
Imbalanced
including
Nutrition:
socialization

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Less than when possible

body
5. Emphasize 5.to provide a
requirements
importance of sense of
well-balanced, control and
nutritious enable the
intake. client to
follow own
progress and
assist w/
making
choices

6.Provide
information
regarding 6.To promote
individual relaxation,
nutritional reduces
needs & ways likelihood of
to meet these stress
needs within
financial
constraints

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Case

Assessment Nursing Diagnosis Analysis Planning Interventions Rationale Evaluation

Subjective Fatigue related Inflammation After 4 hours 1.Review 1.To assess Goal met
cues: to decreased of the liver of nursing medication contributing
After nursing
“Feeling ko, metabolic energy intervention regimen factor (e.g.
intervention
lagi akong production and the client will beta blockers
the client able
pagod,”as altered body Altered liver be able to with fatigue
to report
verbalized by chemistry as function report as a side
improved
the patient. evidenced by improved effect)
2.Assess sense of
reports of lack of sense of
Objective psychological and 2.To assess energy
energy/inability energy
cues: Alteration in causative/
to maintain usual personality
the contributing
routines, factors that may
-irritability metabolism affect reports of factors
decreased
of nutrients
-weakness performance and fatigue level
needed in
increased
-refuse to the body 3.Accept reality
physical 3.To help the
answer of the client
complaints. client to cope
questions report of fatigue with fatigue
Weakness and do not and manage
underestimate within
effect on quality individual
of life the client
Fatigue limits of
experiences activity
4. Plan care to 4.To maximize
allow individually participation
adequate rest
periods. Schedule
activities for

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periods when
client has the
most energy
5.
5. Provide
Temperature
environment
and level of
conducive to
humidity are
relief of fatigue
known to
affect
exhaustion

6. To
6. Refer to maintain/
physical/ increase
occupational strength and
therapy for muscle tone
programmed and to
daily exercises enhance sense
and activities of well-being
7. Provide 7. To assist
diversional client to cope
activities with fatigue

8. Provide 8. To promote
supplemental wellness
oxygen as
indicated

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9.Assist client to 9.Promote

indentify sense of
appropriate control and
coping behavior improves self-
esteem

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Case

Assessment Nursing Diagnosis Analysis Planning Interventions Rationale Evaluation

Subjective Activity Inflammation After 2 hours 1.Note clients 1.To identify Goal met
cues: Intolerance of the liver of nursing reports of causative/ After nursing
related to intervention
“Hindi ako weakness, precipitating intervention
weakness and the patient
makapasok sa fatigue, pain factors the patient
pain secondary to Altered liver will be able to
trabaho dahil was able to
disease process. function verbalize accomplishing
nanghihina verbalized
techniques to
ako,” as tasks and or techniques to
enhance
verbalized by insomnia enhance
activity
the patient. Alteration in activity
intolerance
the 2. Assess 2. Stress/ intolerance.
Objective metabolism
cues: emotional/ depression
of nutrients
needed in physiological may be
-weakness
the body factors affecting increasing the
-cannot
the current affect of an
perform ADL
situation illness, or
Weakness
depression
might be the
Fatigue result of being
forced into
activity
Activity
Intolerance

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3. To prevent
over
3. Adjust
relaxation
activities. Reduce
intensity level or
discontinue
activities that
cause undesired
physiological
changes
4. To reduce
fatigue
4. Plan rest with
care periods
between
activities
5. Helps to
5. Provide minimize
positive frustration,
atmosphere, rechanneled
while
acknowledging
difficulty of the

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situation for the 6. To enhance

client ability to
participate in
6. Promote
activities
comfort measures
and provide relief 7. To enhance
of pain sense of well
being
7. Encourage
client to maintain
positive attitude;
suggest use of
relaxation
techniques, such
as visualization/
guided imagery 8. To sustain
inappropriate motivation

8. Give client To promote

wellness
information that
provides evidence
of daily weekly
progress

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Assessment Nursing Analysis Planning Interventions Rationale Evaluation

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Diagnosis

Subjective Hyperthermia Inflammation After 2 hours 1. Monitor vital 1. To assess Goal met.
cues: related to of the liver of nursing signs and core physiologic After the
inflammatory interventions temperature functioning nursing
“Sumasakit process the patient’s interventions,
ang ulo ko at 2. Promote 2. To reduce
temperature the patient’s
giniginaw surface cooling by body
of 39.4 0C will temperature is
ako,” as Inflammatory means of temperature or 37 0C.
be lowered to
verbalized by process undressing. restore normal
at least 370C.
the patient. Promote cool body or organ
environment and function
Objective apply Tepid
cues: Sponge Bath or
Vital signs: Elevated body emersion
temperature especially in groin
T-39.40C and axillae.
(Hyperthermia)
P-100bpm 3. Note 3. Evaporation
presence/absence is decrease by
R-26bpm
of sweating as environmental
BP- body attempts to factors of high
110/80mmHg increase heat loss humidity and
by evaporation, high ambient
-WBC=10.4 conduction and temperature as
mg/L diffusion. well as body
factors
-U/A= pus-4-6
producing loss
of ability to
sweat or sweat

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glands
dysfunction.
4. Monitor used
hyperthermia 4. To minimize
blanket and wrap shivering.
extremities with
bath towel

5. Administer
medication as 5. To treat
indicated. underlying
cause or
infection for
malignant
hyperthermia.

6. To reduce
6. Maintain bed metabolic
rest. demands and
oxygen
consumption

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