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edema formation CAUSE 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. 3rd edition. by Lemone and Burk. pg. 594) CUES OBJECTIVES NURSING INTERVENTIONS INDEPENDENT: Subjective: “Punga ako tiyan” as verbalized by the patient. STO: Within 30 minutes of nursing interventions, the patient will verbalized understanding on proper food selection like low sodium diet. 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. 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. 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: Abdominal girth47.1 inches (+) Crackles Bounding pulse. REFERENCES: Medical-Surgical Nursing. Vol. 1. 3rd ed. by Lemone and Burk. pg. 594 Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Vol. 2, 10th ed. By Smeltzer and Bare. pg. 1109 Administer diuretics, Furosemide (Lasix) Albumin, Aldacton, Promotes excretion of fluid through the kidneys and maintenance of normal fluid and electrolyte balance. 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. After 30 minutes of nursing interventions, the patient verbalized understanding on proper food selection like low sodium diet. RATIONALE STO: EVALUATION
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
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.
0 sec LTO: Within 2 days of effective nursing intervention. impaired manufacture of coagulation factors II. and X. IX. Vol. 2010 Patient -54. and increased platelet destruction due to splenomegaly. 2. signs of hypovolemic shock. Institute bleeding precautions. Preventive measures can decrease the risk for active bleeding. 10th ed. by Lemone and Burk. 2010) -PROTHROMBINE TIME : April 18. VII. pg. 1. colonic bacteria enter he systemic circulation. the pt. Coagulation studies help determine the risk for bleeding and the nee for treatment. Visitors and health care workers with active infection are to avoid contact with patient. would maintain/demonstrate improvement in laboratory values such as absence of WBC in the urine and blood. hematochezia (bright blood in the stool) or tarry stools. 3rd edition. 1.NURSING CARE PLAN PROBLEM: Risk for Injury NURSING DIAGNOSIS: Risk for injury: Bleeding r/t disease process and destruction of Kupffer cells CAUSE ANALYSIS: Impaired coagulation. 594 Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. this is due to destruction of Kupffer cells that are unable to perform phagocytosis thus. by Lemone and Burk. Vol. Report abnormal results. increased (Urinalysis. 1110 . 1. After 2 days of effective nursing intervention. Reduced contact to infection. Rebleeding is common is common following variceal hemorrhage. Monitor vital signs. 4. 3. report tachycardia or hypotension. Collaborative: 5. the pt. 3. as verbalized by the patient 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. (Medical-Surgical Nursing. Vol. Carefully monitor the client who has had bleeding esophageal varices for evidence of rebleeding: hematemasis. 1. 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. 1. Clotting is altered by vitamin K deficiency. esophageal varices and possible gastritis place the client with cirrhosis at significant risk for hemorrhage. 5.1 sec Control – 14. 2. 2. Also. was not able to maintain/demonstrate improvement in laboratory values such as absence of WBC in the urine and blood. page 594-595) CUES OBJECTIVES NURSING INTERVENTIONS INDEPENDENT: RATIONALE EVALUATION Subjective: “Naa lage bun-og ako kamot”. 3rd edition. pg. By Smeltzer and Bare. To prevent hemorrhage REFERENCES: Medical-Surgical Nursing. Monitor coagulation studies and platelet count. especially within the first week. Increase pulse and decreasing blood pressure may indicate hypovolemia due to hemorrhage. Administer Vitamin K 1. April 17. 4. Objectives: -Bruises on both upper extremities -WBC: 8-12.
clean hands.NURSING CARE PLAN PROBLEM: Itching NURSING DIAGNOSIS: Risk for impaired Skin Integrity related to pruritus from jaundice and edema CAUSE ANALYSIS: Severe jaundice with bile salt deposits on the skin may cause pruritus. Institute measures to prevent skin and tissue breakdown: Turn at least every 2 hours. the patient was able to regain integrity of skin surface by application of measures in minimizing skin itching. RATIONALE EVALUATION Subjective: “ Katol kaayo ako panit’. 3. 595) CUES OBJECTIVES STO: Within 8 hours of nursing care. Vol. Objectives: -rash -reddening of skin -single firm lesions -scaling 3. (Medical-Surgical Nursing. Scratching related to the pruritus damages the skin and impairs skin integrity. 2. avoid soap or preparations with alcohol. the patient was not able to regain integrity application of measures in minimizing skin itching. 1. Such as avoiding to harsh skin care products. apply mittens to the hands to prevent scratching. by Lemone and Burk. 1107 . well trimmed nails. Use measures to prevent dry skin: Apply an emollient or lubricant as needed to keep skin moist. and frequently assess skin condition. By Smeltzer and Bare. as verbalized by the patient 1. After 3 days of nursing care. the patient was not able to described measures to protect the skin. Hot water increases pruritus. DEPENDENT: 1. particularly protein deficiency. 4. 4. Dry skin contributes to pruritus. by Lemone and Burk. 2. 3rd edition. 10th ed. NURSING INTERVENTIONS INDEPENDENT: 1. the patient will be able to describe measures to protect the skin. 3rd edition. Use warm water rather than hot water when bathing. Such as avoiding to harsh skin care products. To decrease the itchiness of the skin. If indicated. and edema also increase the risk for tissue breakdown and impaired skin integrity. REFERENCES: Medical-Surgical Nursing. Clients with encephalopathy may not understand the need to refrain from scratching. Frequent position changes relieve pressure and promote circulation and tissue oxygenation. use an alternating pressure mattress. After 8 hours of nursing care. 595 Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 2. pg. Malnutrition. Apply calamine lotion 1. 1. Vol. pg. Vol. LTO: Within 3 days of nursing care. pg. and do not rub the skin.
NURSING CARE PLAN PROBLEM: Anorexia NURSING DIAGNOSIS: Imbalanced Nutrition: Less than Body Requirements related to abdominal fullness and discomfort and anorexia CAUSE ANALYSIS: The client with cirrhosis is at risk for malnutrition for a number of reasons: possible chronic alcohol use. pg. Vol. 3rd edition. (Medical-Surgical Nursing. by Lemone and Burk. impaired vitamin and mineral absorption and impaired protein metabolism. 595 . 1. anorexia.
4. It activates metabolic function and supports the energy balance of the liver. RATIONALE STO: 1. The dietitian can provide detailed instructions. Instruct to weigh at least weekly at home. GODEX is a multicomponent drug containing Carnitine orotate.prevents fat accumulation and protects cell membrane integrity. 2. A small meal is more appealing for an anorexic client. Because of their peculiar role in whole-body nitrogen metabolism and the competitive action on amino acid transport across the blood–brain barrier. EVALUATION Within eight hours of initiating nursing interventions patient will be able to demonstrate increase appetite as evidence by consuming enough diet as indicated. 3. patient was able to demonstrate behaviors/lifestyle changes to regain or maintain appropriate weight. promote protein and nutrient intake by providing nutritional supplements such as Ensure or Instant Breakfast. The sodium and protein content of all meals and snacks must be calculated when maintaining restrictions of these nutrients. 2. Liver cell regeneration is stimulated and the bile is stabilized. GODEX: 1. was able to demonstrate increase appetite as evidence by consuming enough fitting diet as indicated. LTO: After eight hours of initiating nursing interventions patient. 2010) Decreased muscle tone Appears weak Muscle grade. • Administer multivitamins such as: Essentiale forte 4. detoxifies acyl groups and ROS. LTO: After three days of initiating nursing interventions. cyanocobalamin. 5. Objectives: 1/3 of food served consumed (April 18 & 19. Weigh daily.restores elctron balance for greater energy • Aminoleban • Mitodex (Godex) . pyridoxine HCl. 3. Unless protein is restricted due to impending hepatic encephalopathy. 4.CUES Subjective: “ Dili siya ganahan mukaon” as verbalized by the SO. Weight is a good indicator of both nutritional status and fluid balance. Provide oral hygiene.2 Within three days of initiating nursing interventions patient will be able demonstrate behaviors/lifestyle changes to regain or maintain appropriate weight. Arrange for consultation with a dietitian for diet planning while hospitalized at home. 2. It restores enzyme functions and promotes detoxification of the liver. while longer-term changes in weight are more reflective of nutritional status. and riboflavin which acts synergistically. Neutral fats and cholesterol are transformed into transportable forms and led to their physiological oxidation. Regulates membrane permeability and improves the exchange of substances between the intra. Short-term weight fluctuations tend to reflect fluid balance. and suggestions for improving the palatability of the dient and promoting intake. provides efficient mitochondrial energy system. 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.and extracellular space. Collaborative: 1. sample menus. Between-meal snacks help maintain adeuate calorie and nutrient intake. 3. adenine HCl. Provide small meals with between meal snacks. STO: OBJECTIVES NURSING INTERVENTIONS INDEPENDENT: 1.
by Lemone and Burk. 10th ed. By Smeltzer and Bare. the decreased bile salts enable to diminished fat emulsification and absorption leading to weight loss and general weakness. Vol. 3rd edition. CAUSE ANALYSIS: Due to bile salts accumulation in the blood. 1107 NURSING CARE PLAN PROBLEM: Body Malaise NURSING DIAGNOSIS: Activity Intolerance related to fatigue. Decreased in strength may be due to inefficient circulation of blood to a part of the body. pg. 2. [Medical Surgical Nursing By Smeltzer and Bare] .REFERENCES: Medical-Surgical Nursing. pg. Decrease in strength in muscles in any part of the body can lead to immobilization. Vol. 1. lethargy and malaise secondary to liver cirrhosis. 595 Brunner & Suddarth’s Textbook of Medical-Surgical Nursing.
pg. Administer suplemental vitamins (A. By Smeltzer and Bare. 10th ed. Asses level of activity tolerance and egree of fatigue. 5. To provides additional nutrients. C. 2. 1107 NURSING CARE PLAN PROBLEM: Edema/Ascites . 5. Encourage rest when fatigued or when abdominal pain or discomfort occurs. Stimulates patient’s interest in selected activities. Provides calories for energy and protein for healing. lethargy and malaise when performing routine ADLs. 2. the patient will maintain/increase strength and function of affected or compensatory body parts as evidenced by coordination. Provide diet high in carbohydrates with protein intake consistent with liver function. the patient was not able to maintain/increase strength and function of affected or compensatory body parts as evidenced by coordination. and increased muscle strength. • REFERENCES: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Assist with activities and hygiene when fatigued. B complex. Conserves energy and protects the liver. 3. 1. and K). Provides baseline for further assessment and criteria for assessment of effectiveness of interventions. 2. DEPENDENT: 1. normal ROM. 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 • 1.CUES OBJECTIVES NURSING INTERVENTIONS INDEPENDENT: RATIONALE EVALUATION Subjective: “ kahoy kaayo ako lawas”. normal ROM. 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. Promotes exercise and hygiene within patient’s level of tolerance. 3. and increased muscle strength. Assist with selection and pacing of desired activities and exercise. 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. 1. 4. Vol. as verbalized by the patient. 4.
6. Provides information for assessing impact ofchanges in appearance. Encourage and assist patient in decision making about care.hirsutism. and role function CAUSE ANALYSIS: In liver cirrhosis. 7. 4. Recognition and acknowledgment of the harmful effects of these practices are necessary for identifying a healthier lifestyle. pp. and role on the patient and family. 2. 5. RATIONALE EVALUATION Objectives: -pitting edema grade 3 -skin rashes -bruises LTO: After 3 days of giving nursing intervention. relief of anxiety and adaptation to altered body image and will be able to verbalize understanding of body changes. 3. 10th ed. 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. deepening of voice. Assist and encourage patient to maximize appearance and explore alternatives to previous sexual and role functions. 2. the patient will be able to recognize and incorporate body image change into self concept in accurate manner without negating self esteem. Enables patient to identify and express concerns. pg. Identify with patient resources to provide additional support (counselor. and increase virilism. respectively. increased Na and water retention causes edema due to fluid shift to extravascular compartment leading to edema. 2. encourages patient and significant others to share these concerns. Encourages patient to continue safe roles and functions while encouraging exploration of alternatives. 4. Endocrine function is also altered with increased/elevated androgen and estrogen levels in the blood of male and female. Vol. Encourage patient to verbalize reactions and feelings about these changes. the patient will be able to verbalize acceptance of self in situation. sexual dysfunction. Assess patient’s and family’s previous coping strategies. fall of body hair. Assists patient in identifying resources and accepting assistance from others when indicated. spiritual advisor). 8. 1. and will be able to acknowledge self as an individual who has responsibility to self. Accomplishing these goals serves as positive reinforcement and increases self-esteem. acne. 6. 5. Promotes patient’s control of life and improves sense of well-being and self-esteem 7. Permits encouragement of those coping strategies that are familiar to patient and have been effective in the past. 1108-1109 NURSING CARE PLAN . REFERENCES: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. LTO: After 3 days the patient was able to recognized and incorporated body image into self-concept in accurate manner without negating selfesteem and was able to acknowledge self as an individual who has responsibility for self. 1. sexual function. In female . Assist patient in identifying previous practices that may have been harmful to self (alcohol and drug abuse). (Medical Surgical Nursing – Udan. 8. Common manifestations include gynecomastia. Assess changes in appearance and the meaning these changes have for patient and family.NURSING DIAGNOSIS: Disturbed body image related to changes in appearance. decreased libido. 3. atrophy of testicles in male. By Smeltzer and Bare. Assist patient in identifying short-term goals. 333) CUES OBJECTIVES NURSING INTERVENTIONS INDEPENDENT: Subjective: “nidako lage ako tiyan” as verbalized by the patient. STO: After 2 days in giving nursing intervention.
Reduce sodium and fluid intake if prescribed. due to imapired gastrin in the blood causes excessive stimulation of the stomach parietal cells leading to oversecretion of acid. Vol. Removal of ascites fluid may decrease abdominal discomfort. 2. Subjective: Pt. 5. and fluid in the thoracic cavity . The liver edge is palpable. Reduces irritability of the gastrointestinal tract and decreases abdominal pain and discomfort. absence of muscle tension and restlessness. patient will be free from pain as evidenced by stable v/s. pp. By Smeltzer and Bare. is nodular. Minimizes further formation of ascites. pg.when respiration and moving Q-stabbing R-whole abdomen S-6/10 T. Prepare paracentesis. Reduces metabolic demands and protects the liver.when moving felt for about 2 minute 2. 3. DEPENDENT: patient and assist with 5. Provides baseline to detect further deterioration of status and to evaluate interventions. 10th ed. CAUSE ANALYSIS: In liver cirrhosis. 4. 4. 1109 NURSING CARE PLAN PROBLEM: Difficulty of breathing NURSING DIAGNOSIS: Ineffective breathing pattern related to ascites and restriction of thoracic excursion secondary to ascites. REFERENCES: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 3. Maintain bed rest when experiences abdominal discomfort. rapid enlargement of the liver. LTO: After 8 hours of effective nursing intervention. producing tension on the fibrous covering of the liver (Glisson’s capsule). Also. patient verbalized pain scale 0f 2/10. 1102) CUES OBJECTIVES STO: Within 1-2 hours of implementing nursing interventions. NURSING INTERVENTIONS INDEPENDENT: 1. patient will be able to verbalize pain relief at a level of from a scale 1/10 verbalizes feelings of reasonable comfort. abdominal pain may be present because of recent. RATIONALE EVALUATION STO: Objective partially met. absence of muscle tension and restlessness.PROBLEM: Abdominal Pain NURSING DIAGNOSIS: Acute pain and discomfort related to enlarged tender liver and ascites and oversecretion of acid. patient 1. Administer antispasmodic and sedative agents as prescribed. and report presence and character of pain and discomfort. patient was able to be free from pain as evidenced by stable v/s. 2. (Med-Surg Nursing by Bare. Observe. abdominal distention. P. record. may verbalize pain at the abdominal area. Later in the dse the liver decreases in size as scartissue contracts the liver tissue. Objectives: -restless -muscle tension present -irritable -facial grimace LTO: Within 8 hours of effective nursing intervention.
2. Vol. a. b. (Med-Surg Nursing by Carol Porth) CUES OBJECTIVES STO: Within 1-2 hours of nursing interventions. and difficulty of breathing. Have patient void before paracentesis. 6. Promotes expansion and oxygenation of all areas of the lungs. Elevate head of bed to at least 30 degrees. Subjective: “lisud kaayo iginhawa”. thus tachypnea occurs to compensate more oxygen demand and carbon dioxide as stimulator for respiration. c.<3 3. Administer O2 @ 10 l/min and the 6. 1. NURSING INTERVENTIONS INDEPENDENT: 1. 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. patient will participate in actions to maximize oxygenation as evidenced by participating in deep-breathing exercises. Reduces abdominal pressure on the diaphragm and permits fuller thoracic excursion and lung expansion. Assist with paracentesis 4. DEPENDENT: 4. to promote bronchodilation REFERENCES: Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. as verbalized by the patient. LTO: Within 3 days of implementing nursing interventions. and difficulty of breathing. d. patient was not able to experience maximal pulmonary ventilation and adequate gas exchange by absence of pallor.CAUSE ANALYSIS: In liver cirrhosis. Paracentesis is performed to remove fluid from the abdominal cavities may be frightening to the patient. 5. By Smeltzer and Bare. Prevents inadvertent bladder injury. 2. Administer Salbutamol. a. Change position every 2 hours. pg. Reduces requirements. Helps obtain patient’s cooperation with procedures. 3. 10th ed. Record both the amount character of fluid aspirated. 2. RATIONALE EVALUATION STO: After 1-2 hours of nursing interventions. Support and maintain position during procedure. coughing exercise. Conserve patient’s strength by providing rest periods and assisting with activities. Provides record of fluid removed and indication of severity of limitation of lung expansion by fluid. metabolic and oxygen 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. patient was able to participate in actions to maximize oxygenation as evidenced by participating in deep-breathing exercises. 5. 1111 NURSING CARE PLAN . coughing exercise. patient will be able experience maximal pulmonary ventilation and adequate gas exchange by absence of pallor. Prevents inadvertent organ or tissue injury. c. Explain procedure and its purpose to patient.To provide adequate oxygen inhalation LTO: After 3 days of implementing nursing interventions. b. d.
people every shift. 3. Conserves the pt’s energy and allows the pt. Failure to attedn physical needs promptly would serve to increase anxiety. Attend the primary promptly. RATIONALE STO: After 4 hrs. 6. 5. physical needs 4. Support groups can provide ongoing assistance after discharge. Methods that can be used successfully to decrease anxiety. to practice and become comfortable in skills with supporting environment.restlessness -increased BP. 5. Helps identify connection between the precipitating cause and the anxiety experience. Helps determine pathologic effects of anxiety. to learn recognizes and identifies the signs and symptoms of anxiety. will be able to display decrease anxiety state as evidenced by cooperation and conversant to the health care team. will be able to be knowledgeable enough about on how to develop good coping skills. calm. events. Refer the pt. Assist pt. REFERENCES: Clinical Applications of Nursing Diagnosis by Cox. It affects the five dimensions yet it is more on psychoaspect of the person. of rendering effective nursing care the pt. Determines what has helped and determines whether these measures are still useful. become anxious and deppressed leading to contribution to body stress. to fucos on coping with and reducing anxiety. Identification of the behavior and causative factors enhances intervention plans. CUES Subjective: No verbal cues STO: Within 4 hrs. 2. 6. Monitor the vital signs per shift. 3. Reference: General Psychology by Bustos page 35-38.95 LTO: Within 8 hrs. was knowledgeable enough about on how to develop good coping skills. of rendering effective nursing interventions the pt. focus on conversation or activity.140/100 -increased HR. of rendering effective nursing care the pt.PROBLEM: Anxiety NURSING DIAGNOSIS: Anxiety related to threat to or change in health status associated with stress CAUSE ANALYSIS: Disease is the major cause of psychological disturbances of most individual. of rendering effective nursing interventions the pt. Assist the pt. displayed decrease anxiety state as evidenced by cooperation and conversant to the health care team. Conveys calm and helps the pt. 4. Monitor anxiety behavior and relationship to activity. et al pages 456-458 NURSING CARE PLAN . OBJECTIVES NURSING INTERVENTIONS INDEPENDENT: 1. DEPENDENT: 1. DEPENDENT: 1. the abillity to follow instruction or cooperation in plan of care decreases. Other may not sleep but others can do cope with it. From time to time the pt. 2. When anxiety increases. Objectives: . Provide environment. H. in developing coping skills. When the individual knows that he/she is ill the first alteration is the behavioral and followed by the psychological. to a collaborative with appropriate community resources for care. Assist in determining the effects of anxiety. Allows the pt. EVALUATION LTO: After 8 hrs. none threatening 1.
experienced signs of anxiety and fatigue 6.23-25 breathes per min PR. 2. 5. Monitor daily activities. 3. of rendering effective nursing care the pt. This stimulation is triggered by the circulating baroreceptors that activate the sympathetic nervous system to increase excitability. quantity and equality of peripheral pulses. Measure and document input and output. color. of rendering effective nursing interventions the pt. LTO: Objectives: RR. Excessive emotional reaction can affect vital signs of the pt. Note pt. response to its vital signs. Useful in determining fluid needs or identifying fluid excess which compromise cardiac output and oxygenation. Administer IV fluids as ordered. will be able to take resting periods to stabilized the PR and RR. will be able to experience no signs of anxiety and fatigue. 1. 4.. Reference: Medical Surgical Nursing by Ignatavicius and Workman page 929. of rendering effective nursing interventions the pt. Encourage use of relaxation technique such as deep breathing. Monitor output. NURSING CARE PLAN . 4. CUES OBJECTIVES NURSING INTERVENTIONS INDEPENDENT: Subjective: No subjective cues STO: Within 4 hrs. Record skin temperature. 1. Maintains adequate circulating volume and enhance oxygen carrying capacity. DEPENDENT: 1. 1. fluid replacement and stress. Regular activities and mobility stimulates circulation and promotes feeling of well-being. anxiety and fatigue. 5. 3. et al pages 124-125. of rendering effective nursing care the pt. Tachycardia is common response to discomfort and anxiety likewise with pain perceived by the pt. was able to take resting periods to stabilized the PR and RR. 6. May indicate decrease oxygenation as a result of diminished cardiac output. After 4 hrs.90-95 Appears weak Within 8 hrs. RATIONALE STO: EVALUATION LTO: After 8 hrs. 2. H.PROBLEM: Tachycardia NURSING DIAGNOSIS: Altered Tissue Perfusion related to psychological and physical changes associated with fluctuations of peripheral pulse rates CAUSE ANALYSIS: When the person becomes stressful and anxious the symphathetic nervous system will be stimulated thus increasing the heart rate of the individual. Evaluate the presence of physical stress. Monitor the trends in heart rate and blood pressure. REFERENCES: Clinical Applications of Nursing Diagnosis by Cox. Reduced in circulatory volume which negatively affects perfusion.
Doenges. Observe for cyanosis in skin: note especial color of tongue and oral mucous membrane. M. Position client in either semi-fowlers position or side lying position 2. To promote enough oxygen 1. Dependent: 1. and thoracic or abdominal breathing. agitation. confusion 5. 4. NURSING INTERVENTIONS Independent: 1. A. 6. RATIONALE Promote good ventilation and breathing. the patient will be able to know positioning techniques that improve ventilation.23-25 breathes per min O2 sat -87-88 (+) crackles Long term objective: After 3 days of giving effective nursing intervention and health teaching. 6. 3. the patient will demonstrate improve ventilation as evidence by blood gases within client’s normal parameters. and effort. Administer oxygen supply inhalation appropriately. 3. Monitor respiratory rate. To provide bronchodilation. Will promote mucoid or sputum excretion from the lungs Proper assessment will help identify early problems. EVALUATION After 8 hours 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. Changes in behavior and mental status can be early signs of impaired gas exchange Central cyanosis in tongue and oral mucosa is indication of serious hypoxia and is a medical emergency. Geissler-Murr. 2. 468-469) CUES Subjective: No verbal cues OBJECTIVES Short term objective: After 8 hours of giving effective nursing intervention and health teaching. M. depth. Surg. Monitor client’s behavior and mental status for onset of restlessness.pp. the patient was able to know positioning techniques that improve ventilation. 5.199-200 NURSING CARE PLAN PROBLEM: Risk for Aspiration . Objective: Use of accessory muscles Labored breathing (shallow breathing) RR. Bare pp. Administer salbutamol 6 Reference: Nursing care Plan: Guidelines for individualizing patient car.( Med. including use of accessory muscles. Peripheral cyanosis seen in extremities may not be serious. Nursing by S. 2. extreme lethargy 1. After 3 days of giving effective nursing intervention and health teaching. and in the late stages.F Moorhouse.PROBLEM: Crackles NURSING 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.ed . Smeltzer and B. nasal flaring. 2. Encourage client to cough as tolerated. 4.
Surg. or when an NGT is improperly positioned and feedings are instilled into the pharynx or the trachea. Smeltzer & B. X-ray verification of placement is the only consistently reliable method to detect inadvertment respiratory placement. Bare pp. 5. Check for gastric residual at least every 8 hours and before feedings.(Med. 6. Stop continual feeding temporarily when turning or moving client. 6. keep feeding tube securely taped. 116-117 NURSING CARE PLAN . 3. 5. The auscultatory air insufflation method is often not reliable in differentiating between gastric or respiratory placement. Nursing by S. the patient was not able to swallow foods appropriately and swallowing impairment will goes back to normal. Objective: Appears weak Use of accessory muscle Difficulty of breathing Long term objective: After the patient will be discharged. the patient was not able to strengthen swallowing reflex when the NGT will be removed. especially if a small bore feeding tube is used. It is difficult to keep the head elevated when turning or moving a client. pH testing can generally predict feeding tube position in the gastrointestinal tract. which diminishes the gag reflex. 2. Check pH of aspirate. During feeding.NURSING DIAGNOSIS: Risk for aspiration related to the presence of nasogastric tube CAUSE ANALYSIS: Aspiration pneumonia occurs when stomach contents or enteral feedings are regurgitated and aspirated. the patient will be able to strengthen swallowing reflex when the NGT will be removed. Laryngeal nerve endings are reduced in the elderly. Carefully check elderly client’s gag reflex and ability to swallow before 1. NURSING INTERVENTIONS RATIONALE EVALUATION 2. if greater than 100 ml. position client with head of bed elevated at least 30 degrees. After the patient will be discharged. Determine placement of feeding tube before each feeding or every 4 hours if continuous feeding. 4. Keeping the client’s head elevated helps keep food in stomach and decrease incidence of aspiration. the patient will be able to swallow foods appropriately and swallowing impairment will goes back to normal. After 2days of giving effective nursing intervention and health teaching. 3. do not rely on air insufflation method. Increased intragastric pressure can result in regurgitation and aspiration. 4. Check to make sure initial feeding tube placement was confirmed by x-ray. follow institutional protocol on holding feeding. 993-994) CUES Subjective: No Verbal Cues OBJECTIVES Short term objective: After 2days of giving effective nursing intervention and health teaching. Reference: Nursing Diagnosis Handbook: A guide to planning care by: Auckley & Ladwig pp. preferably higher. Independent: 1. maintain for 30 to 45 minutes after feeding.
Using multiple learning methods enhances retention of material. Reinforce explanations of risk factors. changing subject away from information being presented or extremes of behavior (withdrawal/euphoria). o o o Provides opportunity for patient to retain information and to assume control/participate in rehabilitation program. individual risk factors. Natural defense mechanisms. and symptoms requiring immediate medical attention. patient was able to verbalize understanding of condition and potential complication. group activities. Reinforces expectation that this will be a “learning experience. as verbalized by the patient. 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. o Objective: patient asking questions about her condition requests for additional information inaccurate follow through of instructions LTO: After 2 days of care. 392) CUES Subjective: “ Wala ko kabalo unsa hinungdan kung ngano nag ka hepa ko”. learn or demonstrate knowledge of health care measure necessary to maintain health. question-and-answer sessions. e.g. such as anger or denial of significance of situation. patient will correctly perform necessary procedures and explain reasons of action. garlic. o Be alert to signs of avoidance. e. ginkgo biloba. Changing to a less formal/structured style may be more effective until patient/SO is ready to accept/deal with current situation. affecting patient’s response and ability to assimilate information. 46. patient will be able to verbalize understanding of condition and potential complication. NURSING INTERVENTIONS Independent: o Assess patient/SO level of knowledge and ability/desire to learn.g. dietary/activity restrictions... programmed books. o Necessary for creation of individual instruction plan. 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. medications. audiovisual tapes. Note: Routine use of supplements/herbal remedies (e. individual risk factors.g. can block learning. (Med-Surg by Brunner and Suddarth pg. RATIONALE EVALUATION After 15 mins of appropriate health teachings. o Present information in varied learning formats. vitamin E) .” Verbalization identifies misunderstandings and allows for clarification. OBJECTIVES STO: After 15 mins of appropriate health teachings.PROBLEM: Lack of information NURSING 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. Fundamentals of Nursing pg. actively participates in regimens given to promote wellness.
Valsalva maneuver. smoking/alcohol consumption. e. o Warn against isometric activity. or dyspnea may require changes in exercise and medication regimen. Note: Sexual activity can be safely resumed once patient can accomplish activity equivalent to climbing two flights of stairs without adverse cardiac effects. may enhance collateral circulation. o o Review programmed increases in levels of activity. development of chest pain. obesity. Differentiate between increased heart rate that normally occursduring various activities and o o o o o Pulse elevations beyond established limits. increase risk for complications.can result in alterations in blood clotting. and allows return to normal lifestyle.. These activities greatly increase cardiac workload and myocardial oxygen consumption and may adversely affect myocardial contractility/output.. walking. e. especially when anticoagulant/ASA therapy is prescribed. as appropriate. and activities requiring arms positioned above head.g. o These behaviors/chemicals have direct adverse effects on cardiovascular function and may impede recovery. work. Identify alternative activities for “bad weather” days. o Encourage identification/reduction of individual risk factors. Review signs/symptoms requiring reduction in activity and notification of healthcare provider. Provide guidelines for gradually increasing activity and instruction regarding target heart rate and pulse taking. Gradual increase in activity increases strength and prevents overexertion.g. Educate patient regarding gradual resumption of activities. Provides for continuing daily activity program. such as measured walking in house or shopping mall. . recreational and sexual activity.
Note: After discharge.” smoking cessation clinics. o Depressed patients have a greater risk of dying 6–18 mo following a heart attack.. or other symptoms recur. dyspnea. o Reinforces that this is an ongoing/continuing health problem for which support/assistance is available after discharge. o Emphasize importance of contacting physician if chest pain.g. and role functioning requiring ongoing support. Stress importance of reporting development of fever in association with diffuse/atypical chest pain (pleural. paroxetine (Paxil). palpitations. pericardial) and joint pain..g.worsening signs of cardiac stress (e. Timely intervention may be beneficial. have been found to be as effective as tricyclic antidepressants but with . “coronary clubs. increased heart rate lasting more than 15 min after cessation of activity. Recommend seeking professional help if depressed feelings persist. and identify community resources/support groups. DEPENDENT o Encourage patient/SO to share concerns/feelings. cardiac rehabilitation programs. chest pain. patients encounter limitations in physical functioning and often incur difficulty with emotional.g. Note: Selective serotonin reuptake inhibitors (SSRIs). o o o Post-MI complication of pericardial inflammation (Dressler’s syndrome) requires further medical evaluation/intervention. social. excessive fatigue the following day). change in anginal pattern. e. Discuss signs of pathological depression versus transient feelings frequently associated with major life events. e. Timely evaluation/intervention may prevent complications. o Stress importance of follow-up care..
Geissler-Murr. & Moorhouse .significantly fewer adverse cardiac complications. Reference: Nursing Care Plan 6th edition by Doenges.