CUES NURSING ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOS
IS
Subjective: According to National
“feeling ko Imbalanced Institute of Diabetes Goal:
lalagnatin body and Digestive and After 30 minutes of
ako dahil sa temperature Kidney Diseases, Nursing
sakit tapos : Cirrhosis is a Interventions, the
sobrang hyperthermi condition in which client will maintain
nanghihina a related to your liver is scarred normal body
na talaga inflammator and permanently temperature.
ako”. y process of damaged. Scar tissue
Cirrhosis. replaces healthy liver Objectives: EFFECTIVENESS
Objective: tissue and prevents 1. After 1 hour of 1. Discuss with the 1. This is for the 1. Was the Client
38.4°C your liver from Nursing client the 7 patient to be able to
Pain in working normally. As Interventions, nonpharmacologi prevent further perform 7
abdomen and cirrhosis gets worse, the client will c measures: infection. nonpharmacolog
lower your liver begins to be able to ic measures?
extremities fail. Cirrhosis has identify 7 a. Record a. Provides
many signs and nonpharmacol temperature baseline to __ met
symptoms, such as ogic measures regularly (every detect fever __ partially
fatigue and severe on how to 4 hours) and to met
itchy skin. They may demonstrate evaluate __unmet
not appear until the behaviors for interventions
liver is badly monitoring
damaged. Causes and b. Encourage fluid b. Increased
include alcoholic liver maintaining intake fluid intake
disease, nonalcoholic appropriate corrects fluid
fatty liver disease, body loss from
chronic hepatitis C, temperature. perspiration
and chronic hepatitis and fever,
B. Cirrhosis increases and it
your chance of getting increases
bacterial infections patient’s
NIH external link, level of
such as urinary tract comfort.
infections and
pneumonia. c. Maintain good c. To prevent
nutrition and overheating
The liver is an adequate fluid in a climate-
important component intake. Offer controlled
in the regulation of cool or warm environment.
core body temperature liquids, as
and, as such, displays appropriate.
significant
physiological and d. Review the d. This is for
metabolic changes in client’s possible
response to different medications thermoregula
temperatures. (e.g., diuretics, tory side
Hyperthermia may certain sedatives effects.
promote vasodilation, and antipsychotic
increase aerobic agents, some
metabolism and heart and blood
induce production of pressure
protective molecules medications, or
such as heat shock anesthesia)
proteins.
e. Recommend e. To prevent
According to Nursing lifestyle changes, overheating
Pocket Guide 14th ed, such as cessation and loss of
Imbalanced body of smoking or regulatory
temperature is a substance use body
failure to maintain (such as mechanisms,
body temperature methamphetamin and to
within normal es), maximize
parameters, which normalization of metabolism
may compromise body weight, to meet
health. nutritious meals, individual
and regular needs.
exercise

f. Apply cool f. Promotes

sponges or reduction of
icebag for fever and
elevated increases
temperature. patient’s
comfort.

g. Avoid exposure g. Minimizes

to infections. risk of
further
infection and
further
increases in
body
temperature
and
metabolic
rate.

2. After 2-3 2. Administer 2. Ibuprofen 2. Was the

minutes of ibuprofen on belongs to a client able to
Health to the patient class of drugs take the
teaching about as ordered by called medication
medication for the Doctor. nonsteroidal ordered by
fever, the anti- the Doctor?
client will inflammatory
administer drugs __met
ibuprofen as (NSAIDs). __partially
ordered by the Other met
Doctor. members of __unmet
this class
include
aspirin,
naproxen
(Aleve),
indomethacin
(Indocin),
nabumetone
(Relafen) and
several
others. These
drugs are
used for the
management
of mild to
moderate
pain, fever,
and
inflammation
. Pain, fever,
and
inflammation
are promoted
by the release
in the body
of chemicals
called
prostaglandin
s. Ibuprofen
blocks the
enzyme that
makes
prostaglandin
s
(cyclooxygen
ase),
resulting in
lower levels
of
prostaglandin
s.

EFFICIENCY
Were the Nursing
Intervention efficient
in solving the Clients
health problem?
__met
__partially
met
__unmet

APPROPRIATENE
SS
Were the Nursing
Intervention
appropriate in
solving the Clients
health problem?
__met
__partially
met
__unmet
 ACCEPTABILITY
Were the Nursing
Intervention accepted
in solving the Clients
health problem?
__met
__partially
met
__unmet

ADEQUACY
Were the Nursing
Intervention adequate
in solving the Clients
health problem?
__met
__partially
met
__unmet

Reference:

Omudhome Ogbru, P. (2020, February 12). Ibuprofen (Advil, Motrin) Side Effects (Alcohol), Uses, Dosage & Pregnancy Safety.
Retrieved November 23, 2020, from https://www.medicinenet.com/ibuprofen/article.htm

Doenges, M., & Murr, A. Impaired Urinary Elimination. In M. F. Moorhouse (Ed.), Nurse's Pocket Guide: Diagnoses, Prioritized
Interventions, and Rationales (15th ed.).

Hinkle, J. & Cheever,K. (2014). Brunner & Suddarth’s Medical Surgical Nursing 10th Edition. Lippincott Williams & Wilkins:
Philadelphia, pg. 1110
Cirrhosis. (2018, March). Retrieved November 23, 2020, from https://www.niddk.nih.gov/health-information/liver-disease/cirrhosis

Thorne, A., Surgery, D., Ubbink, R., Unit, O., Brüggenwirth, I., Nijsten, M., . . . XY, Z. (2020, July 09). Hyperthermia-induced
changes in liver physiology and metabolism: A rationale for hyperthermic machine perfusion. Retrieved November 23, 2020, from
https://journals.physiology.org/doi/abs/10.1152/ajpgi.00101.2020