A Nursing Care Plan on

TETRALOGY OF FALLOT

In Partial Fulfillment to the

Requirements in NCM 216 – RLE

OXYGENATION ROTATION

Submitted to:

SARAH JANE PAMALOAN, RN

Clinical Instructor

Submitted by:

JV J. VILLAHERMOSA

BSN 3L – Group 1

September 03, 2021

 Name of Patient: X Age/Sex: 72/Female Room/Bed #: 321

Chief Complaint: Physician:

Diagnosis:

Date/ Cues Need Nursing Diagnosis Patient Outcome Nursing Intervention Impleme Evaluation
Time ntation
A Subjective: Risk for infection as Within 8 hours of nursing  Establish rapport to the 1
P - Pain Scale of 4 H evidenced by ascites interventions, client must client
R out of 5 E and edema be able to: R: This is to promote trust and
I A - Remain free of participation to your patient.
L L Rationale: infection.
Objective: T Cirrhosis reduces the 3
And specifically, be able  Encourage increased fluid
18, - Abdominal Pain H normal flow of blood to: intake
- Distended P through the liver, raising - Present normal vital R: Fluids help promote diluted
2 Abdomen E pressure in the vein that signs urine, frequent emptying of the
0 - Ascites R carries blood from the - Demonstrate bladder, and reducing the stasis
2 - Edema C intestines and spleen to absence of signs of urine. This ultimately reduces
2 - Temperature: P the liver. Legs and and symptoms of the risk of bladder infection
37.9°C T abdomen are swollen. infection or urinary tract infection.
@ - WBC: 10.06X I Fluid can build in the Increased fluid intake also helps
7 109/L O legs (edema) and the replace fluid lost during fever and
A N belly (ascites) due to helps thin secretions. 7
M increased pressure in  Ensure that any items are
the portal vein. properly disinfected and
sterilized before use
Reference: R: Reduces or eliminate germs
4
Cirrhosis - Symptoms
 Perform hand hygiene
and causes.
before having contact with
(2021). Mayo the patient
Clinic; R: Microorganisms are
https://www.mayocl effectively removed from hands

inic.org/diseases- using friction and running water.

Between procedures, washing
conditions/cirrhosis
minimizes the chance of
/symptoms-
infections spreading from one
causes/syc- 6
part of the body to another.
20351487

‌  Assist clients in carrying

out appropriate skin and
oral hygiene.
R: This could be a measure in
2
order to break the chain of
infection and prevent infection
  Provide analgesic
R: In order to relieve pain before 5
it becomes severe

 Maintain strict asepsis

during intravenous
therapy.
R: Aseptic method reduces the
risk of pathogens being
8
transmitted to or spread between
patients.

 Encourage intake of
protein-rich and calorie-
rich foods and encourage
a balanced diet.
R: Nutritional support and a well-
balanced diet improve the
immune system's reactivity and
the health of all bodily tissues.