Nursing Care Plan Patient’s name: D.D. Nationality: Filipino CC: Bloody urination Attending physician: Dr.

Villanueva ASSESSMENT NURSING DIAGNOSIS Actual/Abnormal cues Subjective: The mother verbalizes, “Nagapangihi siya dugo.” Objective:  Yellowish discoloration of the skin  Ecteric sclera  Pallor  Irritability  Weakness Strengths:  Good family support Weaknesses:  Knowledge deficit about the disease Imbalanced Nutrition: Less than Body Requirements related to diet, inability to process, digest nutrients Age: 7y.o Status: Single Diagnosis: Liver pathology RATIONALE Pathologic Jaundice After 8 hours of nursing intervention, the patient will be able to: a. Demonstrate vital signs within client’s normal range. b. Name the individual risk factors and demonstrate behaviors or techniques to prevent ascites. After 8 hours of nursing intervention, the patient was able to:  BP elevations are usually associated with fluid volume excess but may not occur because of fluid shifts out of vascular space. Pulse rate indicates cardiac workload disease. Respiratory rate indicates pulmonary congestion or edema. Increased body temperature indicates infection.  Provides knowledge base from which client can make informed choices. May promote DESRIED OUTCOMES Sex: Male Address: Brgy. Tangub, Bacolod City

NURSING INTERVENTION

JUSTIFICATION

EVALUATION

Inflammation caused by the disease

Indepenent:  Monitor vital signs: BP, pulse rate, body temperature and respiratory rate.  Review disease process and future expectations. Encourage bed rest when ascites is present.

Definition: Imbalanced Nutrition- Intake of nutrients insufficient to meet metabolic needs.

Extensive degeneration and destruction of hepatocytes

Tissue becomes nodular

Reference: Doenges, Manilynn E., et al.(2009).Nursing Care Plans (8th Edition).Philippines: C & E Publishing, Inc.

Nodules block bile ducts and normal blood flow throughout the liver

c. Identify and initiate necessary lifestyle changes.

Compression caused by the proliferation

 Emphasize the importance of good nutrition. Recommend avoidance of highprotein and salty foods, onions and

digest nutrients recumbency-induced dieresis. With financial constraints of fibrous tissue strong cheeses. Submitted by: Maria Nena Balagtas BN2B .  Proper dietary maintenance and avoidance of foods high in sodium and protein aid in remission of symptoms and help prevent ammonia buildup and further liver damage. Flow alterations in the vascular system and lymphatic bile ducts channels Inability to process.