liver ncp
Content
Assessment Subjective: Objective: (+) crackle in the left side Orthopnea Ascites as evidence by Abdominal girth of 41in. Weght: 54kg (+) bilateral pleural effussion (+) Bipedal edema grade 2 Hct: 34.7
BP: 90/60mm Hg
Diagnosis Fluid Volume Excess in the interstitial space related to liver organ failure as evidenced by ascites and bipedal edema.
Goal Long term goal: After 1 week of nursing intervention the clent will stabilize fluid volume as evidence by decrease weight, edema grade(1) and abdominal girth.
Intervention Restrict sodium and fluid intake (5001000cc) Record I/O accurately Weigh daily and measure abdominal girth Evaluate edematous extremities, change position frequently Place in semi-fowlers position Elevate edematous feet Administer Furosemide 40mg IV now as ordered
Rationale Sodium can have an action of water retention. Provide accurate intake Provides a comparative baseline To reduce tissue pressure and risk of skin breakdown To facilitate mov’t of diaphragm improving respiratory effort To facilitate fluid in the interstitium. Acts as a diuretics
Expected Outcome After 1 week of nursing intervention the client have stabilize fluid volume as evidence by decreased weight( 51 kg) and abdominal girth (37in) and edema (grade 1)
Reference: Nurse’s Pocket Guide by Doenges, Fluid Volume Excess, page 258-261
February 14, 2013
ASSESSMENT Subjective: “Hindi ako makahinga ng mabuti” Objective: (+) Dyspnea (+) Orthopnea (+) Crackles RR: 26 cpm (+) Bilateral pleural effusion
DIAGNOSIS Ineffective Breathing Pattern related to collection of fluid in pleural space
PLANNING After the shift patient will manifest signs of decreased respiratory effort AEB absence of dyspnea
INTERVETIONS Assist patient to a comfortable position, such as: - supporting upper extremities with pillows -providing over bed table with a pillow to lean on -elevating head of bed. Encourage slower and deeper respirations Have client breath into a paper bag, if appropriate Demonstrate diaphragmatic and pursed-lip breathing. Encourage opportunities
RATIONALES These measures promote comfort, chest expansion, and ventilation of basilar lung fields.
EVALUATION After the shift patient have manifested signs of decreased respiratory effort AEB absence of dyspnea.
To assist client in taking control of the situation Expired CO2 will be reinspired thereby slowing respiratory rate To decrease air trapping and for efficient breathing. To prevent
for rest and limit physical activities Schedule necessary activities to provide periods of rest Help patient with ADLs, as needed
February 22, 2013
Administer combivent neb q1 x 3 doses x 10 doses then q6 Perform Chest Physiotherapy Postural drainage Vibration Back Clapping
situations that will aggravate the condition This prevents fatigue and reduces oxygen demands. to conserve energy and avoid overexertion and fatigue Indicated as a Bronchodilato rs To loosen mucus secretion
Reference: Nurse’s Pocket Guide by Doenges, Moorhouse and Murr Ineffective Breathing Pattern, page 151-155
ASSESSMENT Subjective: Objective: Jaundice noted in the skin upon inspection. +2 Bipedal edema Ascites AEB abdominal girth of 41in Dry, scaly and shiny skin
DIAGNOSIS Impaired skin integrity related to altered fluid status AEB by bipedal edema and ascites
PLANNING After the shift patient will participate in prevention measure and treatment program.
INTERVETIONS Maintain strict skin hygiene.
RATIONALES to prevent the spread of bacteria and prevent infection to prevent vasoconstriction Reduces likelihood of progression to skin breakdown To relieve the pressure on the patient’s back To monitor output of patient in order to determine fluid and electrolyte intake and loses To promote hygiene and skin integrity.
EVALUATION After the shift patient will participate in prevention measure and treatment program.
Provide adequate clothing/covers. Observe for reddened/blanc hed areas and institute treatment immediately. Change patient’s position every two hours. Drain urine bag every two hours.
Encourage frequent skin care to significant
other. Also, perform morning care to patient by performing complete bed bath and apply lotion afterwards.
To promote skin moisture, and prevent roughness on skin.
Reference: Nurse’s Pocket Guide by Doenges, Moorhouse and MurrImpaired skin integrity, page 487-489
February 22, 2013
BP: 90/60mm Hg
Diagnosis Fluid Volume Excess in the interstitial space related to liver organ failure as evidenced by ascites and bipedal edema.
Goal Long term goal: After 1 week of nursing intervention the clent will stabilize fluid volume as evidence by decrease weight, edema grade(1) and abdominal girth.
Intervention Restrict sodium and fluid intake (5001000cc) Record I/O accurately Weigh daily and measure abdominal girth Evaluate edematous extremities, change position frequently Place in semi-fowlers position Elevate edematous feet Administer Furosemide 40mg IV now as ordered
Rationale Sodium can have an action of water retention. Provide accurate intake Provides a comparative baseline To reduce tissue pressure and risk of skin breakdown To facilitate mov’t of diaphragm improving respiratory effort To facilitate fluid in the interstitium. Acts as a diuretics
Expected Outcome After 1 week of nursing intervention the client have stabilize fluid volume as evidence by decreased weight( 51 kg) and abdominal girth (37in) and edema (grade 1)
Reference: Nurse’s Pocket Guide by Doenges, Fluid Volume Excess, page 258-261
February 14, 2013
ASSESSMENT Subjective: “Hindi ako makahinga ng mabuti” Objective: (+) Dyspnea (+) Orthopnea (+) Crackles RR: 26 cpm (+) Bilateral pleural effusion
DIAGNOSIS Ineffective Breathing Pattern related to collection of fluid in pleural space
PLANNING After the shift patient will manifest signs of decreased respiratory effort AEB absence of dyspnea
INTERVETIONS Assist patient to a comfortable position, such as: - supporting upper extremities with pillows -providing over bed table with a pillow to lean on -elevating head of bed. Encourage slower and deeper respirations Have client breath into a paper bag, if appropriate Demonstrate diaphragmatic and pursed-lip breathing. Encourage opportunities
RATIONALES These measures promote comfort, chest expansion, and ventilation of basilar lung fields.
EVALUATION After the shift patient have manifested signs of decreased respiratory effort AEB absence of dyspnea.
To assist client in taking control of the situation Expired CO2 will be reinspired thereby slowing respiratory rate To decrease air trapping and for efficient breathing. To prevent
for rest and limit physical activities Schedule necessary activities to provide periods of rest Help patient with ADLs, as needed
February 22, 2013
Administer combivent neb q1 x 3 doses x 10 doses then q6 Perform Chest Physiotherapy Postural drainage Vibration Back Clapping
situations that will aggravate the condition This prevents fatigue and reduces oxygen demands. to conserve energy and avoid overexertion and fatigue Indicated as a Bronchodilato rs To loosen mucus secretion
Reference: Nurse’s Pocket Guide by Doenges, Moorhouse and Murr Ineffective Breathing Pattern, page 151-155
ASSESSMENT Subjective: Objective: Jaundice noted in the skin upon inspection. +2 Bipedal edema Ascites AEB abdominal girth of 41in Dry, scaly and shiny skin
DIAGNOSIS Impaired skin integrity related to altered fluid status AEB by bipedal edema and ascites
PLANNING After the shift patient will participate in prevention measure and treatment program.
INTERVETIONS Maintain strict skin hygiene.
RATIONALES to prevent the spread of bacteria and prevent infection to prevent vasoconstriction Reduces likelihood of progression to skin breakdown To relieve the pressure on the patient’s back To monitor output of patient in order to determine fluid and electrolyte intake and loses To promote hygiene and skin integrity.
EVALUATION After the shift patient will participate in prevention measure and treatment program.
Provide adequate clothing/covers. Observe for reddened/blanc hed areas and institute treatment immediately. Change patient’s position every two hours. Drain urine bag every two hours.
Encourage frequent skin care to significant
other. Also, perform morning care to patient by performing complete bed bath and apply lotion afterwards.
To promote skin moisture, and prevent roughness on skin.
Reference: Nurse’s Pocket Guide by Doenges, Moorhouse and MurrImpaired skin integrity, page 487-489
February 22, 2013
