NEUROLOGICAL ASSESSMENT

 NURSING CARE PLAN FOR THE PATIENT WTH HEPATIC CIRRHOSIS

Nursing diagnosis	Goal	Interventions	Rationale	Remarks
Fluid volume excess related to compromised regulatory mechanisms secondary to cirrhosis of the liver as manifested by pallor, weak in appearance, jaundice, abdominal distension and edema	Maintaining fluid volume and decreased edema	Assess the hydration status	It will provide a baseline data	Patient demonstrated stabilized fluid volume with maintained Intake and output.
		Assess respiratory status , noting increased respiratory	Indicative of pulmonary congestion or edema
		Assess the degree of peripheral and dependent edema	Fluid shift into tissues as a result of sodium and water retention
		Monitor blood pressure	BP elevations are usually associated with fluid volume excess
		Monitor intake and output chart	It reflects circulating volume status
		Monitor serum albumin and electrolytes, particularly potassium and sodium	Decreased serum albumin affects plasma colloid osmotic pressure, resulting in odema formation
		Encourage bed rest, when ascites is present with leg elevated to mobilize edema and ascites.	Bed rest may promote recumbency - induced diuresis
		Provide frequent mouth care.	Decreases sensation of thirst especially when fluid intake is restricted

Nursing diagnosis	Goal	Interventions	Rationale	Remarks
Imbalanced nutrition: less than body requirements related to loss of appetite and decreased GI motility secondary to ascites as evidenced by refusal to eat, weak in appearance, irritability, poor muscle tone, emaciated and abdominal distension	Improving nutritional status	Assess the dietary intake and nutritional status through diet	It will provide a baseline data	After using above nursing interventions patient's appetite improved and nutritional status maintained
		Provide high protein, high calorie diet supplement by vitamin A, D, E, K and folic acid.	Indicative of pulmonary congestion or edema
		Encourage and provide small, frequent diet	Fluid shift into tissues as a result of sodium and water retention
		Provide adequate oral hygiene before meal	BP elevations are usually associated with fluid volume excess
		Provide assistance with activities as needed	It reflects circulating volume status
		Administer medications for nausea and vomiting as per doctor's orders	Decreased serum albumin affects plasma colloid osmotic pressure, resulting in odema formation

Nursing  diagnosis	Goal	Interventions	Rationale	Remarks
Activity intolerance related to generalized body weakness secondary to progressive disease state as manifested by pallor, body malaise, diaphoresis, inability to concentrate, and inability to perform ADLs, weak in appearance, limited ROM and difficulty initiating movements	Maintenance of rest and comfort	Assess the degree of activity tolerance and degree of fatigue	Provide baseline data for better interventions.	After using above nursing interventions the patient participate willingly in necessary activities, learned how conserve energy and verbalized relief from fatigue
		Provide adequate rest	Rest  reduces metabolic demands on the liver
		Adjust the patient in a comfortable position in bed	Proper positioning helps in maximal respiratory efficiencies and prevents bedsores
		Encourage patient to take high protein and caloric diet frequently	Provide energy and helps in healing of tissues
		Administer Oxygen as ordered	Oxygenate damaged cells and prevent further damage.
		Encourage the patient to exercise gradually.	Regular exercise improves activity intolerance
		Encourage the client to do whatever possible e.g self-care	Provide for sense of control and feeling of accomplishment

 

Nursing diagnosis	Goal	Interventions	Rationale	Remarks
Risk for impaired skin integrity related to altered circulation secondary to accumulation of bile salts as evidenced by pruritis, erythema, dry and scaly skin	Maintaining skin integrity	Assess the degree of discomfort related to edema	Provides baseline data for better interventions	After using above nursing interventions patient maintained skin integrity and identified  individual risk factors and demonstrated behaviour techniques prevents skin breakdown.
		Inspect the skin surface / pressure points routinely	Edematous tissues are most prone to breakdown and to the formation of decubitus ulcers
		Frequently change the position of the patient	Pressure on the edematous tissues to improve circulation
		Avoid irritating soaps and use of adhesive tape.	May cause trauma to the skin
		Provide back massage with emollient lotion every 2 hours	Improves blood circulation and prevent bed sores
		Use alternative pressure mattress or low air liss bed	Prevent pressure ulcers
		Keep patients fingernails short and smooth	Minimize scratching of the skin
		Keep linen dry and free of wrinkles	Moisture aggrevates pruritis and increases risk of skin breakdown

 

 

 

 

 

 

 

 

Nursing diagnosis	Goal	Interventions	Rationale	Remarks
Knowledge deficit related todisease and long term treatment	Providing knowledge	Assess the knowledge level of patient & family members by asking questions about disease	Provides baseline data for better interventions	Patient verbalized understanding of disease process , potential complications, and identified necessary lifestyle changes and participate in care.
		Encourage the patient for adequate rest and nutritious diet	Provide early recovery from disease
		Stress importance of avoiding alcohol	Alcohol is leading cause in the development of cirrhosis
		Encourage the patient to report any complication	Absence of complication helps in early recover