Nursing Background Goal Nursing Rationale Evaluation

diagnosis knowledge interventions

Subjective: Readiness Lifestyle After 1 hr of 1. establis 1. To gain Goal was

“Sumasakit for nursing h the trust met. After 1
sa bandang enhanced Decrease intervention rapport of the hr of
kanan ng comfort blood the patient patient nursing
aking tiyan” related to volume flow will intervention
(cramping enlarged of the liver Increased the patient
in the right tender liver level of verbalize
side of and ascites Inflammatio comfort decreased
abdomen) n in pain and
abdominal
Objective: Swollen discomfort
Pain scale: liver
7/10
Facial Lesions
grimace
Irritability RUQ pain
Discomfort
Abdominal
Tenderness
2. Maintai 2. Reduces
n bed metabolic
rest demands
when and
patient protects
experien the liver
ces
abdomi
nal
discomf
ort.
3. Observe 3. Provides
, record baseline
and to detect
report further
presenc deteriora
e and tion of
characte status and
r of pain to
and evaluate
discomf interventi
ort ons
4. Reduced 4. Minimizes
sodium further
 and fluid formation
intake of of ascites
prescrib
ed.
5. Encoura 5. Distractio
ge the n may
use of limit the
distracti perceptio
ng n of pain
activities
such as
music,
reading
or
meditati
on
Dependent: 6. Reduces
6. Adminis irritability
ter of the
antipas gastrointe
modic stinal
and tract and
analgesi decreases
c agents abdomina
as l pain and
prescrib discomfor
ed. t
7. Prepare 7. Removal
patient of ascites
and fluid may
assist decrease
with abdomina
procedu l
res for distention
manage
ment of
ascites
such as
paracen
tesis or
TIPS
procedu
re, if
indicate
d