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XI. Nursing Care Plan
Cues/Data Subjective: “Kapoy ako lawas” as verbalized by the client. Objective: >Pallor >Body malaise noted >inability to perform usual ADLs >Weak in appearance >Limited ROM >Dec. Hgb. Level: 11.9 g/dl
Nursing Diagnosis
Scientific Basis
Goals of Care
Nursing Interventions
Activity intolerance related to body weakness secondary to progressive disease state as manifested by body malaise, weak in appearance, limited ROM.
Altered fat metabolism may result in a fatty liver. Fat is use by all cell for energy, and altered metabolism my caused fatigue and decrease activity tolerance in many patient.
After 8 hours of nursing interventio ns, patient will participate willingly in necessary activity, will learn how to conserve energy and verbalize relief from fatigue.
>Adjusted activity and reduced intensity of task that may cause undesired physical changes.
Source: Introduction to Critical Nursing 6th Edition by Moseley page 534
>Promoted independence in self-care activities as tolerated. >Encouraged alternating activity with rest.
>Assessed patient ability to perform ADLs noting reports of weakness, fatigue and accomplishing task. >Monitored laboratory result like Hgb. and Hct.
Rationale >To prevent over exertion
>Mild/moderate activities and improved selfesteem are promoted. >Minimized exhaustion and helps balance oxygen supply and demand. >Influences choice of interventions or needed assistance
Evaluation >After 8 hours of nursing interventions, patient participated willingly in necessary activities, learned how to conserved energy and verbalized relief from fatigue. Goal met.
>To identify the extent of deficiency and for better treatment plan
40
XI. Nursing Care Plan
Cues/Data Subjective: “Wala koy gana mokaon” as verbalized by the client. Objective: >Ht. 165 cm >Wt. 57kg >BMI:20.96 >Weak in appearance >Refusal to eat >Irritability noted >Abdominal distention noted >Abdominal girth: 85cm (33.5 inches)
Nursing Diagnosis Imbalance nutrition: less than body requirements r/t loss of appetite as evidenced by refusal to eat, weak in appearance and irritability.
Scientific Basis The majority of the cirrhotic patients unintentionally follow a low caloric diet, a fact that is attributed to various side-effects observed inn cirrhosis. Loss of appetite, which is currently attributed to the presence of cytokines such us tumor necrosis factor a (TNF-a) or alcoholic induced anorexia, are the most common reasons. Also early satiety due to impaired gastric accumulation and impaired expansion capacity of the stomach due to the presence of clinical evidence ascites quiet often lead to an inadequate nutrient intake.
Goals of Care After 8 hours of nursing intervention, patient’s appetite will improve from half plate of what is served to whole plate or totally consume.
Nursing Interventions >Monitored vital signs >Assisted in oral hygiene before meals >Discussed eating habits including food preference >Prevented or minimized unpleasant odors during meal time >Served foods that are attractive and palatable >Recommended small frequent meals
>Restricted intake of caffeine, gasproducing or spicy and excessive hot or cold foods
Rationale >For baseline data >A clean mouth enhance appetite
>to appeal to client likes and dislikes >May have negative effect on appetite
Evaluation After 8 hours of nursing intervention, patient’s appetite improved from 2 tbsp to 5 tbsp per meal. Goal met.
>to stimulate the appetite >Poor tolerance to large meals may due to increased intraabdominal pressure/ascites >Aids in reducing gastric irritation and abdominal discomfort that may impair oral intake/digestion
Source: http://www.medsca 41
XI. Nursing Care Plan pe. com/viewarticle/ 575158_2
>Provided assistance with activities as needed. Promote undisturbed rest periods, especially before meals >Weigh client every after shift
Cues/Data
Nursing Diagnosis
Scientific Basis
Goals of Care
Nursing Interventions
>Conserving energy reduces metabolic demands on the liver and promotes cellular regenerations >to show if there is any changes or improvement in client’s weight
Rationale
Evaluation
42
XI. Nursing Care Plan Subjective: “Init ako pamati” as verbalized. Objective: >temperature 39.9 degree celcius >
43
Cues/Data Subjective: “Kapoy ako lawas” as verbalized by the client. Objective: >Pallor >Body malaise noted >inability to perform usual ADLs >Weak in appearance >Limited ROM >Dec. Hgb. Level: 11.9 g/dl
Nursing Diagnosis
Scientific Basis
Goals of Care
Nursing Interventions
Activity intolerance related to body weakness secondary to progressive disease state as manifested by body malaise, weak in appearance, limited ROM.
Altered fat metabolism may result in a fatty liver. Fat is use by all cell for energy, and altered metabolism my caused fatigue and decrease activity tolerance in many patient.
After 8 hours of nursing interventio ns, patient will participate willingly in necessary activity, will learn how to conserve energy and verbalize relief from fatigue.
>Adjusted activity and reduced intensity of task that may cause undesired physical changes.
Source: Introduction to Critical Nursing 6th Edition by Moseley page 534
>Promoted independence in self-care activities as tolerated. >Encouraged alternating activity with rest.
>Assessed patient ability to perform ADLs noting reports of weakness, fatigue and accomplishing task. >Monitored laboratory result like Hgb. and Hct.
Rationale >To prevent over exertion
>Mild/moderate activities and improved selfesteem are promoted. >Minimized exhaustion and helps balance oxygen supply and demand. >Influences choice of interventions or needed assistance
Evaluation >After 8 hours of nursing interventions, patient participated willingly in necessary activities, learned how to conserved energy and verbalized relief from fatigue. Goal met.
>To identify the extent of deficiency and for better treatment plan
40
XI. Nursing Care Plan
Cues/Data Subjective: “Wala koy gana mokaon” as verbalized by the client. Objective: >Ht. 165 cm >Wt. 57kg >BMI:20.96 >Weak in appearance >Refusal to eat >Irritability noted >Abdominal distention noted >Abdominal girth: 85cm (33.5 inches)
Nursing Diagnosis Imbalance nutrition: less than body requirements r/t loss of appetite as evidenced by refusal to eat, weak in appearance and irritability.
Scientific Basis The majority of the cirrhotic patients unintentionally follow a low caloric diet, a fact that is attributed to various side-effects observed inn cirrhosis. Loss of appetite, which is currently attributed to the presence of cytokines such us tumor necrosis factor a (TNF-a) or alcoholic induced anorexia, are the most common reasons. Also early satiety due to impaired gastric accumulation and impaired expansion capacity of the stomach due to the presence of clinical evidence ascites quiet often lead to an inadequate nutrient intake.
Goals of Care After 8 hours of nursing intervention, patient’s appetite will improve from half plate of what is served to whole plate or totally consume.
Nursing Interventions >Monitored vital signs >Assisted in oral hygiene before meals >Discussed eating habits including food preference >Prevented or minimized unpleasant odors during meal time >Served foods that are attractive and palatable >Recommended small frequent meals
>Restricted intake of caffeine, gasproducing or spicy and excessive hot or cold foods
Rationale >For baseline data >A clean mouth enhance appetite
>to appeal to client likes and dislikes >May have negative effect on appetite
Evaluation After 8 hours of nursing intervention, patient’s appetite improved from 2 tbsp to 5 tbsp per meal. Goal met.
>to stimulate the appetite >Poor tolerance to large meals may due to increased intraabdominal pressure/ascites >Aids in reducing gastric irritation and abdominal discomfort that may impair oral intake/digestion
Source: http://www.medsca 41
XI. Nursing Care Plan pe. com/viewarticle/ 575158_2
>Provided assistance with activities as needed. Promote undisturbed rest periods, especially before meals >Weigh client every after shift
Cues/Data
Nursing Diagnosis
Scientific Basis
Goals of Care
Nursing Interventions
>Conserving energy reduces metabolic demands on the liver and promotes cellular regenerations >to show if there is any changes or improvement in client’s weight
Rationale
Evaluation
42
XI. Nursing Care Plan Subjective: “Init ako pamati” as verbalized. Objective: >temperature 39.9 degree celcius >
43
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