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NURSING CARE PLAN

Name of Patient: PATIENT A Agency/ Area: 5B WARD Diagnosis: Acute Appendicitis________________________ Rating: SUB ECTI !Edumumi. akong ASSESSME NT "B ECTI !E cramping

Nahihirapan

a$domina#

!ga " #inggo na ang naka#ipas nung pa##or hu#i akong dumumi. %& taken as 'o##o(s) BP) ""*+,* PR) ,RR) .* T) /0.5

Im$a#anced Nutrition) 1ess than Bod2 Re3uirements re#ated to ina$i#it2 to process and digest nutrients as e4idenced $2 change in $o(e# 'unction.
Decrease $i#e acid s2nthesis 5 Increase cho#estero# s2nthesis in the #i4er 5 Bi#e supersaturated (ith cho#estero# 5 Precipitates out o' the $i#e 5 6orm stones 5 In'#ammation o' the $#adder 5 Pain 5 A$domina# discom'ort 5 1ack o' interest to ingest '#uid+'ood 5 Inade3uate 'ood intake 5 Im$a#ance Nutrition) #ess than $od2 re3uirements

NURSING DIAGN"SIS

SCIENTI#IC E$PLANATI"N

L"NG%TERM The client will continue to: Express feelings of comfort. Patients stool will be soft and will pass easily. c. Express an understanding of the disease process and treatment regimen. d. Bowel function will return to normal. e. Express positive feelings about herself. Demonstrate adaptive coping behaviors. INTE
". E4a#uate c#ient7s risk R!E 'or ma#nutrition.

"B ECTI! ES

S&"RT%TERM The client will continue to: Express feelings of comfort. Patients stool will be soft and will pass easily. c. Express an understanding of the disease process and treatment regimen. d. Bowel function will return to normal. e. Express positive feelings about herself. Demonstrate adaptive coping behaviors.

NURSING ACTI"NS

RATI"NALE

". Eight2?'i4e percent to -*@ o' the $#ood that #ea4es the stomach and intestines carries nutrients to the #i4er (here the2 are con4erted into su$stances the $od2 can use. The c#ient (ith #i4er d2s'unction o'ten has ma#nutrition $ecause o' inade3uate dietar2 intake due to poor 'ood choices or pre'erence 'or a#coho# rather than 'ood and ma2 current#2 ha4e ma#a$sorption s2ndrome due to ina$i#it2 to process or digest nutrients8 anore<ia8 nausea or 4omiting8 indigestion8 or ear#2 satiet2 associated (ith ascites. Because o' the decreased secretion o' $i#e into the gut8 c#ient ma2 ha4e di''icu#t2 a$sor$ing 'at and 'at?so#u$#e 4itamins A8 D8 E8 and A. These de'iciencies can #ead to such comp#ications as decreased 4ision in .. Determine interest in eating and a$i#it2 to the dark8 due to 4itamin A de'icienc2; $one disease8 due to 4itamin che(8 s(a##o(8 and taste. Discuss eating D de'icienc2; neuro#ogica# impairment8 due to 4itamin E de'icienc2; ha$its8 inc#uding 'ood pre'erences8 and decreased production o' c#otting proteins in the #i4er8 due to into#erances8 or a4ersions. Note a4ai#a$i#it2 4itamin A de'icienc2 BBrett#er8 .**/C. and use o' support s2stems. .. 6actors that a''ect ingestion and digestion o' nutrients. /. Determine dietar2 intake and per'orm ca#orie count i' c#ient is eating. /. Pro4ides in'ormation a$out intake8 needs8 and de'iciencies. 9. Weigh8 as indicated. :ompare changes in :#ient (ith cirrhosis re3uires a $a#anced protein diet pro4iding .8*** '#uid status and recent (eight histor2. to /8*** ca#ories per da2 to permit #i4er ce## regeneration. 9. It ma2 $e di''icu#t to use (eight as a direct indicator o' nutritiona# status in 4ie( o' edema and ascites. Note) Dndigested 'at that passes into the #arge intestine can cause diarrhea and #ead to 5. Assist or encourage c#ient to eat; e<p#ain (eight #oss BBrett#er8 .**/C. reasons 'or the t2pes o' diet. 6eed c#ient i' 5. Impro4ed nutrition is 4ita# to reco4er2. :#ient ma2 eat $etter i' tiring easi#28 or ha4e &= assist c#ient. 'ami#2 is in4o#4ed and pre'erred 'oods are inc#uded as much as :onsider pre'erences in 'ood choices. possi$#e. :#ient and 'ami#2 must understand protein intake 0. Encourage c#ient to eat a## mea#s and #imitations and ho( $est to meet needs and desires (ithin supp#ementar2 'eedings. #imitations. 0. :#ient ma2 demonstrate #oss o' interest in 'ood $ecause o' nausea8 genera#iEed (eakness8 and 'atigueF(hich is o'ten 'irst ,. Recommend or pro4ide sma##8 're3uent reported s2mptom and seen in appro<imate#2 ,*@ o' c#ients (ith mea#s. cirrhosis BTa2#or8 .**>C. >. 1imit such high?sa#t 'oods as canned ,. Poor to#erance to #arger mea#s ma2 $e due to increased soups and 4egeta$#es8 processed meats8 intraa$domina# pressure or ascites. and condiments. Pro4ide sa#t su$stitutes i' >. &a#t #imitations can he#p manage '#uid comp#ications in cirrhosis8 a##o(ed8 a4oiding those containing ammonia. inc#uding ascites or tissue edema. &a#t su$stitutes enhance the -. Restrict intake o' ca''eine and gas? '#a4or o' 'ood and aid in increasing appetite; ammonia potentiates producing or spic2 and e<cessi4e#2 hot or risk o' encepha#opath2. co#d 'oods. -. Aids in reducing gastric irritation8 diarrhea8 and a$domina# "*. Encourage or pro4ide 're3uent mouth discom'ort that ma2 impair ora# intake and digestion. care8 especia##2 $e'ore mea#s. "*. :#ient is prone to sore and $#eeding gums and $ad taste in mouth8 (hich contri$utes to anore<ia.

. b. . d. .

E$PECTED "UTC"ME/ E!ALUATI"N patient will Express feelings of comfort. Patients stool will be soft and will pass easily. Express an understanding of the disease process and treatment regimen. Bowel function will return to normal. Express positive feelings about herself. Demonstrate adaptive coping behaviors

Pre'are( )y:

E*a+,ate( )y:

&tudent Nurse7s &ignature o4er Printed Name DATE:

:#inica# Instructor7s &ignature o4er Printed Name DATE:

Rating: Assessment Nursing Diagnosis &cienti'ic E<p#anation =$Gecti4es Nursing Actions Rationa#e E<pected =utcome+ E4a#uation

P"INTS .5 "5 "* "* .5 "* 5

SC"R E

TRANSMUTED GRADE B0*@ Passing &coreC)

T"TAL :