Central Philippine Adventist College: Specific Objectives

Central Philippine Adventist College
SCHOOL OF NURSING
CLINICAL DIVISION
Bacolod Adventist Medical Center Compound
C.V. Ramos Avenue Taculing, Bacolod City
Tel. No. (034) 433-2407 Fax No. (034) 433-2363
Website: www.cpacsn.info ♦ Email: inquiry@cpacsn.info
O b j e c t i v e s
NAME:_Danielle Audrey Ban, Joshelle YEAR/SECTION:_III_ BLOCKING AREA:Digital RLE WEEKDATE: March 21-23, 2022
Andrade, Windi Dawn Salleva
Specific Objectives:
After 4 hours of digital duty, we will be able to:
K 1. Identify the nursing interventions appropriate for the care of the patient with liver cirrhosis.
2. Determine the clinical manifestation of liver cirrhosis in the patient being cared for.
S 1. Formulate at least 2 nursing care plans for the patient with liver cirrhosis.
2. Conduct a comprehensive drug study of all the patient’s medications in the treatment and
management of liver cirrhosis.
A 1. Value the importance of integrity throughout the care of the patient.
2. Appreciate the role of teamwork in providing a safe and quality care to the patient.
PATIENTS DATA
Name: SHARPAY EVANS Age: Sex: Status:

52 yrs old FEMALE MARRIED
Address: BLK 8, LT 19, SAN ISIDRO, Date of Birth: Place of Birth:

LAPAZ, ILOILO CITY FEBRUARY DON BENITO HOSPITAL, ILOILO CITY
14, 1970
Educ. Attainment: Occupation: Nationality: Religion:
COLLEGE TEACHER FILIPINO SDA
GRADUATE
Date of Admission: Date of Discharge: Hospital #: Case #:
MARCH 21, 2022 22345 000101
Room #: Attending Physician: Medical Diagnosis:

2E20 DR. SILVESTRE STEATOHEPATITIS
OTHER DATA TO BE INCLUDED:
Presumptive diagnosis of cirrhosis attributed to nonalcoholic steatohepatitis, for liver transplant consultation
SCHOOL OF NURSING
CLINICAL DIVISION
Tel. No. (034) 433-2407 Fax No. (034) 433-2363
M a n i f e s t a t i o n s
 Increased abdominal discomfort

 Swelling
 Bilateral lower extremity edema
 Intermitent nausea
 Weakness
 Confusion
 Mildly icteric sclera
 Spider nevi on the anterior chest wall
 Moderately decreased breath sounds
 Mild anemia
 Thrombocytopenia
SCHOOL OF NURSING
CLINICAL DIVISION
Tel. No. (034) 433-2407 Fax No. (034) 433-2363
N u r s i n g A s s e s s m e n t
NAME: ANDRADE, JOSHELLE PHELICIA; BAN, DANIELLE AUDREY; SALLEVA, WINDI DAWN
YEAR/SECTION: III-A BLOCKING AREA: DIGITAL RLE WEEKDATE: MARCH 21-22, 2022
NURSING ASSESSMENT
HEALTH HISTORY
I. Chief Complaint
Abdominal discomfort
II. History of Present Illness

The patient reported increased abdominal discomfort, swelling, and lower extremity edema beginning 7
years earlier, as well as intermittent nausea, weakness, and confusion which had increased in frequency
during the previous year.
While undergoing a cholestectomy for gallstones 2 years previously, the patient was noted to have
ascites and a cirrhotic-appearing liver. Results of routine laboratory tests and an abdominal ultrasound
performed at that time were consistent with cirrhosis.
III. Past Medical History

1. Medical Illness
a. Childhood Illnesses: No history of childhood liver disease
b. Adult Illnesses: Gallstones, GERD, recurrent UTI, and Arthritis.
2. Psychiatric Illnesses: N/A

3. Surgical Procedures: Cholestectomy 2020
4. Accidents/Trauma/Injuries: N/A
5. Other Hospitalizations: 2020 for surgery
6. Immunizations: complete childhood immunization
7. Allergies: No allergies in food and medication
8. Medications:
9. Exposure to Environmental Hazards: N/A
10. Blood Transfusions: N/A
11. Foreign Travel/Military History/Past Residences: N/A
IV. Personal Habits:

Eating out with colleagues and family
V. Psychosocial History/Personal Profile:

The patient reported that 2 of her 7 siblings died from unknown causes as infants, her father died while in
a coma of unknown etiology, her mother died from diabetic complications, and a third sibling died of a
gynecologic cancer.
SCHOOL OF NURSING
CLINICAL DIVISION
Tel. No. (034) 433-2407 Fax No. (034) 433-2363
P h y s i c a l E x a m i n a t i o n
NAME: ANDRADE, JOSHELLE PHELICIA; BAN, DANIELLE AUDREY; SALLEVA, WINDI DAWN
YEAR/SECTION: III-A BLOCKING AREA: DIGITAL RLE WEEKDATE: MARCH 21-22, 2022
PHYSICAL EXAMINATION
1. General Inspection
Patient is awake and answers questions accordingly.
Had a physical appearance that suggested chronic illness but was in no acute distress.
2. Skin
Dry skin, has poor skin turgor (<2 sec), wrinkled, fair in color, no scars noted, rough skin in the palm
3. Nails
No clubbing, trimmed, capillary refill less than 2 secs
4. Head & Face

Hard, smooth and symmetric, round, erect and in midline, black color hair
5. Eyes
Moist, and able to close and open without difficulty, smooth eye movement throughout six direction, mildly icteric sclera,
6. Ears
Equal in size bilaterally, no tenderness, no lesion.
7. Nose & Sinuses

No discharge, no lesion
8. Mouth & Pharynx

No hoarseness, no inflamed tonsils, pink in color, no mouth sores
9. Neck
Symmetric with head center and without bulging and palpable masses
10. Lungs
Moderately decreased breath sounds in her lower left lung were also noted.
11. Heart
Heart rate 90 bpm, no bruits, no murmurs
12. Breasts:
Spider nevi on the anterior chest wall
13. Upper Extremities

No palpable masses noted, aligned with the clavicle
14. Abdomen
+Ascites, unpalpable liver, +abdominal sound
15. Lower Extremities

Bilateral lower extremity edema
16. Spine
Active movement, full range of motion, no pain in mobilization
17. Neurological
Obeys command fully, alert and oriented, spontaneous eye opening
18. Genitourinary:
No palpable masses, no inflammation, no lesion
Central Philippine Adventist Alegria, Murcia,
College Negros Occidental

Info@cpac.edu.ph
School of Nursing
Committed to the development of the whole man
NURSES’
CODE
NOC AM PM
JPA-Joshelle Phelicia S. Andrade, CPAC-SN
DAB-Danielle Audrey G. Ban, CPAC-SN
WDS-Windi Dawn Monique C. Salleva,
CPAC-SN
Day/Shift
Focus Progress Notes (D=Data, A=Action, R=Reaction, E=Evaluation)
Time
March 14, 2022 F1 Imbalanced nutrition D1 2:00 PM Intermittent nausea, (+) weakness, (+) confusion which increased in frequency.-----------DAB
2-10 PM
A1 2:15 PM Assessed patency of the IV lines.-----------------------------------------------------------------------DAB
A1 2:30 PM Measured dietary intake by calorie count.-------------------------------------------------------------DAB
A1 2:45 PM Encouraged to eat all meals including supplementary feedings.--------------------------------DAB
A1 3:00 PM Suggested soft foods, avoiding roughage if indicated.---------------------------------------------DAB
A1 3:15 PM Instructed on reasons for the types of diet in liver cirrhosis treatment.-------------------------DAB
A1 3:30 PM Instructed to refer to dietician for meal plans and preparations.---------------------------------DAB
F2 Excess fluid volume D2 3:45 PM (+) Swelling, and (+) lower exteremity edema.-------------------------------------------------------DAB
A2 4:00 PM Assessed respiratory status, noting increased respiratory rate, dyspnea.--------------------DAB
A2 4:20 PM Assessed degree of peripheral edema.----------------------------------------------------------------DAB
A2 4:50 PM Auscultated heart sounds, noting development of S3/S4 gallop rhythm.----------------------DAB
A2 5:15 PM Auscultated lungs, noting diminished breath sounds and developing adventitious sounds.----
------------------------------------------------------------------------------------------------------------------------------------DAB
A2 5:35 PM Measured abdominal girth.--------------------------------------------------------------------------------DAB
A2 5:50 PM Encouraged bedrest when ascites is present.--------------------------------------------------------DAB
A2 6:15 PM Restricted sodium and fluids as indicated.------------------------------------------------------------DAB

A2 6:30 PM Instructed on methods of relieving edema at home.------------------------------------------------DAB
F3 Risk for impaired skin integrity D3 7:00 PM (+) Bile salts in skin, (+) lower extremity edema.----------------------------------------------------DAB
A3 7:25 PM Inspected pressure points and skin surfaces closely and routinely.----------------------------DAB
A3 7:40 PM Encouraged and assisted with reposition on a regular schedule.-------------------------------DAB
A3 8:00 PM Recommended elevating lower extremities.----------------------------------------------------------DAB
A3 8:30 PM Kept linens dry and free of wrinkles.--------------------------------------------------------------------DAB
A3 8:50 PM Provided perineal care following urination and bowel movement.-------------------------------DAB
R1 9:00 PM Decreased nausea and vomiting, (-) of confusion.--------------------------------------------------DAB
R2 9:15 PM Decreased swelling and edema.-------------------------------------------------------------------------DAB
R3 9:30 PM (-) Itching, (-) jaundicr, (-) presence of bile salts in skin.-------------------------------------------DAB
E 10:00 PM E F1- resolved, decreased nausea and vomiting, (-) of confusion;F2- resolved, decreased
swelling and edema; F3 resolved, (-) Itching, (-) jaundicr, (-) presence of bile salts in skin. Endorsed to
the next shift.-------------------------------------------------------------------DAB Danielle Audrey G. Ban, CPAC-SN
LAST NAME FIRST NAME MI AGE SEX HOSP NUMBER

Evans, Sharpay A. 52 F 22345
Nurses’ FDARE Progress Notes
Page 1
of 2
SCHOOL OF NURSING
CLINICAL DIVISION
Tel. No. (034) 433-2407 Fax No. (034) 433-2363
NURSING HISTORY
HEALTH PATTERNS (GORDON’S FUNCTIONAL MODEL)
Health Perception-Health Nutritional-Metabolic Elimination Pattern Activity-Exercise Pattern
Management
Obese:
Patient has regular consultation of at W: 86 kg BM 1-2 times a day No regular exercise
least every month after diagnosis of H: 153 cm Urinate every 1-2 hours: 40ml
gallstones in 2020 Eats 3 meals a day: 2-3 cups of rice and
viand
Eat snacks in the afternoon and sometimes
at midnight: Noodles or bread, cup of coffee
Sleep-Rest Pattern Sexuality-Reproductive Pattern Cognitive-Perceptual Self-Perception – Self Concept
Sleeps at 10 or 11 pm Married with 1 adult son Patient is awake and answers Patient verbalized that she is
Wakes up at 5 am Menopaused at 50 years old questions accordingly. obese and needs to lose weight
Had a physical appearance that but comfortable and confident
suggested chronic illness but was in no with her appearance.
acute distress.
Bubbly and optimistic.
SCHOOL OF NURSING
CLINICAL DIVISION
Tel. No. (034) 433-2407 Fax No. (034) 433-2363
Role Relationship Coping – Stress Tolerance Recreational Value and Beliefs
Patient is a working mother, and the Patient loves gardening as stress reliever Patient has works at her flower garden, Patient is SDA and goes to
bread winner of the family play with her pets as her recreational church regularly.
activity
SCHOOL OF NURSING
CLINICAL DIVISION
Tel. No. (034) 433-2407 Fax No. (034) 433-2363
D r u g S t u d y
NAME:_Danielle Audrey Ban, Joshelle Andrade, Windi Dawn Salleva YEAR/SECTION:_III_ BLOCKING AREA:Digital RLE WEEKDATE: March 21-23, 2022
Generic/ Classification Indication Purpose Dosage/ Mechanism of Action Nursing Consideration Rationale
Trade Name Time
Brand name: Nutritional Treatment and It plays a role Liver Its involvement in  Assess for the mentioned  To prevent any untoward
Hepa-Pro Supplements Management in the Disease: methylation assists in cautions and complications
Generic name: of: immune  Oral: cellular growth and contraindications (e.g. drug
Ademetionine  Depression system, 1200- repair, maintains the allergies, hepatorenal
 Osteoarthriti maintains 1600 mg phospho-bilipid layer in diseases, psychosis,
s cell per day; cell membranes. glaucoma, etc.)
 Liver membranes, should  Give with food.  To prevent GI upset
Disease and helps not be  Inform patient that the side
 Intrahepatic produce and administ effects include headache,
Cholestasis break down ered for dizziness, feeling anxious,
 Fibromyalgi brain more vomiting, stomach upset,
a chemicals, than 2 diarrhea, constipation,
such as years insomnia (sleep problem),
serotonin,  IV: 200- increased sweating.
melatonin, 2000  Start at a low dose and  Large doses may cause
and mg/day gradually increase it. mania (abnormally
dopamine. for 15-30 elevated mood).
days
 IM: 200
mg/day
for 30
days
Brand name:  Antidiabeti  Monotherap Rosiglitazon Adults: It is a potent agonist for  Monitor serum glucose levels  To determine effectiveness
Avandia c y as an e is used  4 mg as the peroxisome frequently. of drug and dosage being
Generic name:  Thiazolidin adjunct to with a proper a single proliferator-activated used.
rosiglitazone edione diet and diet and oral receptor-gamma, which  Monitor baseline LFTs before
maleate exercise to exercise dose or in turn regulates the beginning therapy and
SCHOOL OF NURSING
CLINICAL DIVISION
Tel. No. (034) 433-2407 Fax No. (034) 433-2363
improve program to divided transcription of insulin- periodically during therapy.

glucose control high into two responsive genes  Arrange for consult with  To establish weight loss
control in blood sugar doses, involved in the control of dietitian program and dietary
patients with in people may be glucose production, control as appropriate.
type 2 with type 2 increase transport and utilization.  Monitor urine or blood for  To evaluate very closely
diabetes diabetes. d to 8 glucose and ketones as while adjusting to drug
 As part of mg daily prescribed
combination PO.
with insulin,  Combina  Educate patient to report
metformin or tion fever, sore throat, unusual
a therapy bleeding or bruising, rash,
sulfonylurea with dark urine, light-colored
when diet, metformi stools, hypo- or
exercise, n: 4 mg hyperglycemic reactions.
and either daily PO
agent alone Combina
does not tion with
result in insulin:
adequate Continue
glycemic insulin
control in dose
type 2 and start
diabetes with 4
 Unlabeled mg/day
use:  Patients
Increased with
ovulation hepatic
frequency in impairm
women with ent: Do
polycystic not
ovary administ
syndrome er if
AST >
2.5
times
the
SCHOOL OF NURSING
CLINICAL DIVISION
Tel. No. (034) 433-2407 Fax No. (034) 433-2363
upper
level of
Brand name:  Antidiabeti  Managemen Adjunct to normal. Improves glycemic  Monitor for S&S
Actos c t of type 2 diet in the Type 2 control in noninsulin hypoglycemia
Generic name:  Thiazolidin diabetes treatment of Diabetes dependent diabetic  Assess peripheral edema
Pioglitazone edione mellitus; type 2 Mellitus (type 2) patients by using girth measurements,
may also be diabetes  Adult: enhancing insulin volume displacement, and
used with a mellitus. PO 15– sensitivity of cells measurement of pitting
sulfonylurea It increases 30 mg without stimulating edema
, metformin, the adipocyte once pancreatic insulin  Monitor signs of anemia,
or insulin uptake of daily secretion. Indicated by including unusual fatigue,
when the fatty acids, (max: 45 improved blood glucose shortness of breath with
combination thereby mg q.d.) levels and decreased exertion, and bruising.
of diet, potentially HbA.  Implement aerobic exercise  To maintain optimal body
exercise, drawing fat and endurance training weight, improve insulin
and away from programs sensitivity, and reduce the
metformin the risk of macrovascular
does not hepatocytes. disease (heart attack,
achieve stroke) and microvascular
glycemic problems (reduced blood
control. flow to tissues and organs
that causes poor wound
healing, neuropathy,
retinopathy, and
nephropathy).
Brand name:  Vitamin  To treat and Significantly Prevents cell membrane  People with diabetes should  Vitamin E might increase
Vitec prevent improves Vitamin E and protein damage and avoid high doses of vitamin E. the risk for heart failure in
Generic name: hemolytic serum Deficiency is essential to the people with diabetes.
Vitamin E anemia due aminotransfe Adult: digestion and  Inform patient that natural
(Tocopherol) to vitamin E rase levels, PO/IM 60– metabolism of sources of vitamin E are
deficiency\ hepatic 75 IU/d polyunsaturated fats. found in wheat germ (the
 To prevent steatosis, Maintains the integrity of richest source) as well as in
retrolental and lobular Prophylaxis cell membranes, vegetable oils (sunflower,
fibroplasia inflammation for Vitamin protects against blood corn, soybean, cottonseed),
SCHOOL OF NURSING
CLINICAL DIVISION
Tel. No. (034) 433-2407 Fax No. (034) 433-2363
secondary compared E Deficiency clot formation by green leafy vegetables, nuts,

to oxygen with placebo Adult: PO decreasing platelet dairy products, eggs, cereals,
treatment in in adults with 12–15 IU/d aggregation, enhances meat, and liver.
neonates, NASH and vitamin A utilization, and  Monitor plasma tocopherol
and in without promotes normal concentrations (normal range:
 Treatment diabetes. growth, development, 6-14 mcg/mL)
of diseases and tone of muscles.
with
secondary
erythrocyte
membrane
abnormalitie
s (e.g.,
sickle cell
anemia, and
G6PD
deficiency
and as
supplement
in
malabsorpti
on
syndromes).
 Used in
patients on
diets
containing
large
amounts of
polyunsatur
ated fats for
long periods
and in the
patient who
abruptly
discontinues
SCHOOL OF NURSING
CLINICAL DIVISION
Tel. No. (034) 433-2407 Fax No. (034) 433-2363
such a diet.
Brand name:  Blood  Managemen PTX Decreased blood  Monitor therapeutic  It is indicated by relief from
Trental viscosity t of increases Intermittent viscosity and improved effectiveness pain and cramping in calf
Generic name: reducing symptomatic hepatic Claudication blood flow, with muscles, buttocks, thighs,
pentoxifylline agent peripheral glutathione Adult: PO 4 consequent reduction of and feet during exercise
vascular levels in 00 mg t.i.d. tissue hypoxia. and improves walking
disease mice with with meals Resultant increased performance (time and
(intermittent steatohepatiti blood flow to the duration).
claudication) s induced by extremities reduces pain  Monitor BP if patient is also  Drug may slightly decrease
. a methionine and paresthesia of on antihypertensive an already stabilized BP,
choline- intermittent claudication; treatment. necessitating a reduced
deficient diet further, dose of the hypotensive
and reduces psychopathologic drug.
the conditions associated  Assess heart rate, ECG, and
production of with cerebral hypoxia heart sounds, especially
oxygen are improved. during exercise (See
radicals Appendices G, H). Report any
induced by rhythm disturbances or signs
prolonged of arrhythmias, including
ischemia palpitations, chest discomfort,
time in rat shortness of breath, dyspnea,
livers. fainting, and
fatigue/weakness.
 Assess heart rate, ECG, and
heart sounds, especially
during exercise (See
Appendices G, H). Report any
rhythm disturbances or signs
of arrhythmias, including
palpitations, chest discomfort,
shortness of breath, dyspnea,
fainting, and
fatigue/weakness.
SCHOOL OF NURSING
CLINICAL DIVISION
Tel. No. (034) 433-2407 Fax No. (034) 433-2363
Reference:
https://www.medindia.net/doctors/drug_information/ademetionine.htm
https://www.stlukes-stl.com/health-content/medicine/33/000324.htm
https://go.drugbank.com/drugs/DB00118
https://www.apollopharmacy.in/salt/ADEMETIONINE#:~:text=ADEMETIONINE%20belongs%20to%20the%20class,to%20treat%20S%2Dadenosylmethionine%20deficiency.
https://www.rnpedia.com/nursing-notes/pharmacology-drug-study-notes/rosiglitazone-maleate/
https://www.webmd.com/drugs/2/drug-17298/rosiglitazone-oral/details
https://fadavispt.mhmedical.com/content.aspx?bookid=1873&sectionid=139022541
http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/P050.html
http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/V022.html
https://www.rxlist.com/vitamin_e/supplements.htm
https://www.syrianclinic.com/med/en/ProfDrugs/VitaminEpd.html
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7868704/
https://fadavispt.mhmedical.com/content.aspx?bookid=1873&sectionid=139022028#:~:text=Instruct%20patient%20to%20report%20other,bloating%2C%20indigestion%2C%20
flatulence).
http://www.robholland.com/Nursing/Drug_Guide/data/monographframes/P030.html
Central Philippine Adventist College Alegria, Murcia,
School of Nursing Negros Occidental
Committed to the development of the whole man info@cpac.edu.ph
Nursing Care Plan
Medical
Blocking : OB Surgical
POSTPARTUM Area : Station
PHPC IIIII Weekdate: March 21-23, 2022
Shift : PM
Student Nurse: Danielle Audrey Ban, Joshelle Phelicia Andrade, and Windi Dawn Monique Salleva
Patient’s Name: SHARPAY EVANS Actual/ Provisional Diagnosis: LIVER CIRRHOSIS

Nursing Problem: IMBALANCED NUTRITION LESS THAN BODY REQUIREMENTS
Outcomes
Assessment Nursing Diagnosis Nursing Interventions Rationale Evaluation
/Objectives
O (Observation/ Assessment)
Imbalanced nutrition Long Term -Assess the patency of the IV lines -To ensure that the correct fluids are given at Long Term
Objective Data: less than body Objective: -Record intake and output from the emesis and the prescribed rate. Objective:
 PTA: The patient requirements r/t After 8 hours of wound drainage systems. -To determine fluid balance. After 8 hours of
reported intermittent nausea nursing intervention -Monitor laboratory studies: serum glucose, -Glucose may be decreased because of nursing intervention the
increased and weakness. the patient will be prealbumin and albumin, total protein, ammonia. impaired gluconeogenesis, depleted glycogen patient was able to
abdominal able to stores, or inadequate intake. Protein may be demonstrate
discomfort, demonstrate low because of impaired metabolism, progressive weight gain
swelling, and progressive weight decreased hepatic synthesis, or loss into toward goal with
lower extremity gain toward goal peritoneal cavity (ascites). Elevation of patient-appropriate
edema beginning with patient- ammonia level may require restriction of normalization of
7 years earlier, as appropriate protein intake to prevent serious laboratory values
well as normalization of complications.
intermittent laboratory values
nausea, M (Management) Short Term
weakness, and Independent Nursing Interventions Objective
confusion which Short Term
had increased in Objective -Measure dietary intake by calorie count. -Provides important information about intake, After 2 hours of
frequency during -Weigh as indicated. Compare changes in needs and deficiencies. nursing intervention
the previous year. After 2 hours of fluid status, recent weight history, skinfold -Skinfold measurements are useful in the client was able to
nursing measurements. assessing changes in muscle mass and experience no further
Vital Signs: intervention the -Encourage patient to eat all meals subcutaneous fat reserves. signs of malnutrition.
 BP:120/80mmHg client will be able including supplementary feedings. -Patient may pick at food or eat only a few bites
 RR: 20bpm to experience no -Provide salt substitutes, if allowed; avoid because of loss of interest in food or because of
 PR: 89bpm further signs of those containing ammonium. nausea, generalized weakness, malaise. After 15 minutes of
 Temp: 37.3°C malnutrition. -Suggest soft foods, avoiding roughage if -Salt substitutes enhance the flavor of food and client teaching the
indicated. aid in increasing appetite; ammonia potentiates patient was able to
risk of encephalopathy. verbalize the
Nursing Care Plan
After 15 minutes of -Hemorrhage from esophageal varices may importance of diet in
client teaching the occur in advanced cirrhosis. the recovery phase of
patient will be able liver cirrhosis.
to verbalize the
importance of diet Collaborative Interventions Goal met.
in the recovery -Collaborate with other medical providers in -To seek help from the entire healthcare team
phase of liver in running diagnostic tests, as well as in the in evaluating and creating an effective
cirrhosis. psychosocial needs of the patient. management strategy.
-Provide tube feedings, TPN, lipids if -May be required to supplement diet or to
indicated. provide nutrients when patient is too
-Refer to dietitian to provide diet high in nauseated or anorexic to eat or when
calories and simple carbohydrates, low in fat, esophageal varices interfere with oral intake.
and moderate to high in protein; limit sodium -High-calorie foods are desired inasmuch as
and fluid as necessary. Provide liquid patient intake is usually limited. Carbohydrates
supplements as indicated. supply readily available energy. Fats are
poorly absorbed because of liver dysfunction
and may contribute to abdominal discomfort.
Proteins are needed to improve serum protein
levels to reduce edema and to promote liver
cell regeneration.
E (Education)
- Instruct patient about reasons for the types -Improved nutrition and diet is vital to recovery.
of diet in liver cirrhosis treatment. Patient may eat better if family is involved and
preferred foods are included as much as
possible.
References:
Vera, M. (2022). 8 Liver Cirrhosis Nursing Care Plans. Retrieved from https://nurseslabs.com/8-liver-cirrhosis-nursing-care-plans/
Nursing Care Plan
Blocking : Medical Surgical Area :Station III Weekdate: March 21-23, 2022
Shift : PM

Nursing Problem: EXCESS FLUID VOLUME
Outcomes
/Objectives
Excess fluid volume Long Term -Assess respiratory status, noting increased -Indicative of pulmonary congestion. Long Term
Objective Data: r/t compromised Objective: respiratory rate, dyspnea. -Fluids shift into tissues as a result of sodium Objective:
 PTA: The patient regulatory mechanism After 8 hours of -Assess degree of peripheral edema. and water retention, decreased albumin, and After 8 hours of
reported as evidenced by nursing intervention -Monitor BP and CVP if available. Note JVD and increased antidiuretic hormone (ADH). nursing intervention the
increased lower extremity the patient will be abdominal vein distension. -BP elevations are usually associated with fluid patient was able to
abdominal edema. able to -Monitor for cardiac dysrhythmias. Auscultate volume excess but may not occur because of demonstrate stabilized
discomfort, demonstrate heart sounds, noting development of S3/S4 fluid shifts out of the vascular space. fluid volume, with
swelling, and stabilized fluid gallop rhythm. Distension of external jugular and abdominal balanced I&O, and
lower extremity volume, with -Monitor serum albumin and electrolytes veins is associated with vascular congestion. stable weight.
edema beginning balanced I&O, and (particularly potassium and sodium). -May be caused by HF, decreased coronary
7 years earlier, as stable weight. -Auscultate lungs, noting diminished breath arterial perfusion, and electrolyte imbalance.
well as sounds and developing adventitious sounds. -Decreased serum albumin affects plasma
intermittent -Measure abdominal girth. colloid osmotic pressure, resulting in edema Short Term
nausea, formation. Objective
weakness, and Short Term -Increasing pulmonary congestion may result After 2 hours of
confusion which Objective in consolidation, impaired gas exchange, and nursing intervention
had increased in After 2 hours of complications. the client was able to
frequency during nursing -Reflects accumulation of fluid (ascites) verbalize decreased
the previous year. intervention the resulting from loss of plasma proteins/fluid into degree of peripheral
client will be able peritoneal space. edema in the lower
Vital Signs: to verbalize extremity.
 BP:120/80mmHg decreased
 RR: 20bpm degree of M (Management)
 PR: 89bpm peripheral edema Independent Nursing Interventions
 Temp: 37.3°C in the lower
extremity. -Measure I&O, weigh daily, and note gain -To assess circulating volume status,
of more than 0.5 kg/day. developing or resolution of fluid shifts, and
response to therapeutic regimen.
Nursing Care Plan
-Encourage bedrest when ascites is -May promote recumbency induced diuresis. After 15 minutes of
After 15 minutes of present. -Decreases sensation of thirst. client teaching the
client teaching the -Provide frequent mouth care; occasional -Sodium may be restricted to minimize fluid patient was able to
patient will be able ice chips (if NPO). retention in extravascular spaces. Fluid verbalize methods of
to verbalize -Restrict sodium and fluids as indicated. restriction may be necessary to correct relieving edema.
methods of dilutional hyponatremia.
relieving edema. Goal met.
Collaborative Interventions -To seek help from the entire healthcare team
-Collaborate with other medical providers in in evaluating and creating an effective
in running diagnostic tests, as well as in the management strategy.
psychosocial needs of the patient. -Albumin may be used to increase the colloid
-Administer salt-free albumin/plasma osmotic pressure in the vascular compartment
expanders as indicated. (pulling fluid into vascular space), thereby
-Administer diuretics increasing effective circulating volume and
-Administer potassium decreasing formation of ascites.
-Administer positive inotropic drugs and -Used with caution to control edema and
arterial vasodilators. ascites, block effect of aldosterone, and
increase water excretion while sparing
potassium when conservative therapy with
bedrest and sodium restriction does not
alleviate problem.
-Serum and cellular potassium are usually
depleted because of liver disease and urinary
losses.
-Given to increase cardiac output/improve renal
blood flow and function, thereby reducing
excess fluid.
E (Education) -To enhance knowledge and reduce anxiety.
- Instruct patient about methods of relieving
edema at home.
References:
Vera, M. (2022). 8 Liver Cirrhosis Nursing Care Plans. Retrieved from https://nurseslabs.com/8-liver-cirrhosis-nursing-care-plans/2/
Nursing Care Plan
Blocking : Medical Surgical Area : Station III Weekdate: March 21-23, 2022
Shift : PM

Nursing Problem: RISK FOR IMPAIRED SKIN INTEGRITY
Outcomes
/Objectives
Risk for impaired skin Long Term -Inspect pressure points and skin surfaces -Edematous tissues are more prone to Long Term
Objective Data: integrity r/t presence Objective: closely and routinely. Gently massage bony breakdown and to the formation of decubitus. Objective:
 PTA: The patient of lower extremity After 8 hours of prominences or areas of continued stress. Use Ascites may stretch the skin to the point of After 8 hours of
reported edema. nursing intervention of emollient lotions and limiting use of soap for tearing in severe cirrhosis. nursing intervention the
increased the patient will be bathing may help. patient was able to
abdominal able to maintain maintain skin integrity.
discomfort, skin integrity.
swelling, and M (Management)
lower extremity Independent Nursing Interventions Short Term
edema beginning Short Term Objective
7 years earlier, as Objective -Encourage and assist patient with -Repositioning reduces pressure on edematous After 2 hours of
well as After 2 hours of reposition on a regular schedule. Assist tissues to improve circulation. Exercises nursing intervention
intermittent nursing with active and passive ROM exercises as enhance circulation and improve and/or the client was able to:
nausea, intervention the appropriate. maintain joint mobility.  Identify individual
weakness, and client will be able -Recommend elevating lower extremities. -Enhances venous return and reduces edema risk factors
confusion which to: -Keep linens dry and free of wrinkles. formation in extremities.  Demonstrate
had increased in  Identify -Suggest clipping fingernails short; provide -Moisture aggravates pruritus and increases behaviors/techniq
frequency during individual risk mittens/gloves if indicated. risk of skin breakdown. ues to prevent
the previous year. factors -Provide perineal care following urination -Prevents patient from inadvertently injuring the skin breakdown.
 Demonstrate and bowel movement. skin, especially while sleeping.
Vital Signs: behaviors/tec -Use alternating pressure mattress, egg- -Prevents skin excoriation breakdown from bile
 BP:120/80mmHg hniques to crate mattress, waterbed, sheepskins, as salts.
 RR: 20bpm prevent skin indicated. -Reduces dermal pressure, increases
 PR: 89bpm breakdown. circulation, and diminishes risk of tissue
 Temp: 37.3°C ischemia.
Nursing Care Plan
After 15 minutes of Collaborative Interventions -To seek help from the entire healthcare team After 15 minutes of
client teaching the -Collaborate with other medical providers in in evaluating and creating an effective client teaching the
patient will be able in running diagnostic tests, as well as in the management strategy. patient was able to
to explain the steps psychosocial needs of the patient. -May be soothing and can provide relief of explain the steps in
in preventing skin -Use calamine lotion and provide baking soda itching associated with jaundice, bile salts in preventing skin
breakdown in her baths. Administer medications (as indicated) skin. breakdown in her own
own words. such as cholestyramine (Questran), words.
hydroxyzine (Atarax), diphenhydramine
(Benadryl).
Goal met.
E (Education)
- Instruct patient that skin folds and areas -To enhance knowledge, promote self-care,
vulnerable to skin injury should be cleaned and enhance cooperation to one’s care.
and dried several times a day. Alcohol-based
lotions and harsh soaps, as well as talcum
powders, should be avoided in these areas. If
necessary, dry cloths to absorb moisture can
be left in skin folds in between washing and
drying of the skin folds.
References:
Vera, M. (2022). 8 Liver Cirrhosis Nursing Care Plans. Retrieved from Vera, M. (2022). 8 Liver Cirrhosis Nursing Care Plans. Retrieved
from https://nurseslabs.com/8-liver-cirrhosis-nursing-care-plans/2/

Central Philippine Adventist College: Specific Objectives

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Central Philippine Adventist College: Specific Objectives

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Central Philippine Adventist College

A 1. Value the importance of integrity throughout the care of the patient.

Name: SHARPAY EVANS Age: Sex: Status:

Address: BLK 8, LT 19, SAN ISIDRO, Date of Birth: Place of Birth:

Room #: Attending Physician: Medical Diagnosis:

OTHER DATA TO BE INCLUDED:

 Increased abdominal discomfort

II. History of Present Illness

III. Past Medical History

b. Adult Illnesses: Gallstones, GERD, recurrent UTI, and Arthritis.

2. Psychiatric Illnesses: N/A

IV. Personal Habits:

V. Psychosocial History/Personal Profile:

4. Head & Face

7. Nose & Sinuses

8. Mouth & Pharynx

13. Upper Extremities

15. Lower Extremities

College Negros Occidental

A2 6:15 PM Restricted sodium and fluids as indicated.------------------------------------------------------------DAB

LAST NAME FIRST NAME MI AGE SEX HOSP NUMBER

Sleep-Rest Pattern Sexuality-Reproductive Pattern Cognitive-Perceptual Self-Perception – Self Concept

Role Relationship Coping – Stress Tolerance Recreational Value and Beliefs

improve program to divided transcription of insulin- periodically during therapy.

secondary compared E Deficiency clot formation by green leafy vegetables, nuts,

Patient’s Name: SHARPAY EVANS Actual/ Provisional Diagnosis: LIVER CIRRHOSIS

Patient’s Name: SHARPAY EVANS Actual/ Provisional Diagnosis: LIVER CIRRHOSIS

Patient’s Name: SHARPAY EVANS Actual/ Provisional Diagnosis: LIVER CIRRHOSIS

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