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

 

Nursing Care of Patients with Diabetes

 

DIABETES MELLITUS

Definition:

Diabetes is a group of metabolic diseases characterized by increased levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both.

Types and Causes

1.      Type 1 Diabetes Mellitus

Type 1 diabetes (formerly called juvenile diabetes mellitus, insulin-dependent diabetes mellitus, or IDDM) is caused by destruction of the beta cells in the islets of Langerhans of the pancreas. When the beta cells are destroyed, they are unable to produce insulin.

2.      Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (formerly called adult-onset diabetes mellitus, non–insulin-dependent diabetes mellitus, or NIDDM). In type 2 diabetes mellitus, tissues are resistant to insulin.

3.      Gestational Diabetes

Gestational diabetes mellitus (GDM) occurs in pregnancies, especially in women with risk factors for type 2 diabetes. The extra metabolic demands of pregnancy trigger the onset of diabetes.

4.      Prediabetes

Prediabetes usually occurs before the onset of type 2 diabetes. Those with prediabetes may be able to prevent the onset of diabetes with weight loss and exercise.

5.      Other Types of Diabetes

·       Secondary diabetes can develop as a result of another chronic illness that damages the islet cells, such as pancreatitis or cystic fibrosis.

·       Prolonged use of some drugs, such as steroid hormones, phenytoin, thiazide diuretics, and thyroid hormone, can also impair insulin action and raise blood glucose.

·       Less common causes include pancreatic trauma and other endocrine disorders.

Risk factors:

·       Physical inactive

·   First degree relative with diabetes

·       Hypertension ≥ 140/90 mm Hg.

·       HDL cholesterol < 35 mg/dL and/or triglyceride level >250 mg/dL.

·       Diagnosis of prediabetes

·       Prior history of GDM

·       History of cardiovascular disease

·       History of insulin resistance

Signs and Symptoms:

·       Polydipsia (excessive thirst),

·       Polyuria (excessive urination), and

·       Polyphagia (excessive hunger).

·       Fatigue and weakness,

·       Sudden vision changes,

·       Tingling or numbness in hands or feet,

·       Dry skin, skin lesions

·       Delayed wound healing and

·       Recurrent infections.

Pathophysiology:

                      Diet high in Carbohydrates
                          + Sedantary life Style
                                      + Genetic

                                             ⬇️

              Insulin levels increase in blood stream

                                             ⬇️ 

                      Cell becomes resistant to insulin

                                             ⬇️

                      Blood glucose levels becomes high

                                             ⬇️

                                   Type 2 Diabetes

Diagnostic Criteria:

1.      Fasting Plasma Glucose Level

When the fasting plasma glucose is 126 mg/dL or greater, diabetes is diagnosed.

If the fasting plasma glucose is between 100 and 125 mg/dL, the patient has prediabetes.

2.      Random Plasma Glucose

Diabetes is diagnosed if the Random Plasma Glucose is 200 mg/dL or greater, with symptoms of diabetes.

3.      Oral Glucose Tolerance Test

An OGTT measures blood glucose at intervals after the patient drinks a concentrated carbohydrate drink. Diabetes is diagnosed when the blood glucose level is 200 mg/dL or greater after 2 hours. A result between 140 and 199 mg/dL at 2 hours leads to a diagnosis of impaired glucose tolerance and prediabetes.

4.      Glycohemoglobin

The glycohemoglobin test (also called glycosylated haemoglobin, or HbA1c [haemoglobin A1C]). It reflects the average blood glucose level for the previous 2 to 3 months.

A normal HbA1c is 4% to 6%.

An HbA1c of 6.5% or higher is diagnostic for diabetes.

An HbA1c between 6% and 6.5% indicates prediabetes.

Complications of Diabetes Mellitus.

Complications associated with diabetes are classified as acute and chronic.

1.      Acute complications are:

·       Hypoglycemia

·       Hyperglycemia and Diabetes Keto Acidosis (DKA)

·       Hyperglycemic Hyperosmolar Non-ketotic Syndrome (HHNS)

2.      Chronic complications are:

v  Macrovascular (large vessel) disease:

·       Coronary vascular disease

·       Cerebrovascular disease

·       Hypertension

·       Peripheral vascular disease

v  Microvascular (small vessel) disease:

·       Diabetic Retinopathy

·       Diabetic Nephropathy

·       Neuropathy

·       Diabetic foot ulcer

Management:

Medical management for clients diabetes includes restoring and maintain blood glucose levels as near as possible by

1.      Balanced diet,

2.      Exercise,

3.      Use of oral hypoglycemic agents or insulin,

4.      Health education and

5.      Monitoring by follow-up and check ups.

1.      Balanced diet:

§  A balanced diet low in carbohydrate, low in fat and cholesterol is ideal for diabetes.

§  Advice the patient to avoid junk foods.

§  Instruct to increasing intake of low glycemic food.

§  Advice to eat lot of fibre rich diet and drink adequate amount of water

§  Advice to eat small frequent meals than three large meals.

§  Weight reduction is a primary treatment of type 2 diabetes.

2.      Exercise :

§  Exercise is important factors in controlling blood glucose and lipid level.

§  Regular scheduled, moderate exercise performed for at least 30 minutes per day.

§  An aerobic exercise, strengthening exercise, and stretching exercise can help the diabetic patients

3.      Oral hypoglycemic agents:

§  Alpha-glucosidase inhibitors (AGIs) Blocks the action of enzymes in digestive tract that break down the carbohydrates. Example: Acarbose

§  DPP-4 inhibitor Inhibits DPP-4, an enzyme that breaks incretins. Example: Sitagliptin

§   Biguanides Decreases glucose production by liver; increases glucose uptake by muscle. Example: Metformin

§ Thiazolidinediones Reduce insulin resistance in muscles. Example: Pioglitazone, Rosiglitazone

§  Sulfonylureas Stimulate insulin secretion by pancreas, increase insulin receptor sensitivity. Example : glipizide, glimepiride, glyburide

4.      Insulin:

§  Insulins are available in rapid-acting, short-acting, intermediate-acting, and long-acting preparations.

§  Insulin is administered by sterile, single-use needles and either disposable insulin syringes or a multiple dose insulin pen.

§   Insulin injections should be given in a different subcutaneous site with each dose to avoid tissue injury.

§  Aspirating for blood before injection and rubbing the site after injection are not recommended with insulin injections.

Nursing Diagnoses:

·       Imbalanced Nutrition: less than body requirements  

         related to insulin deficiency

·       Fear related to medication injection.

·       Risk for unstable blood glucose level related to effect of insulin                     

·       Activity Intolerance related to poor glucose control.

·       Deficient Knowledge related to use of oral hypoglycemic agents and injectable agents.

·       Risk for Impaired Skin Integrity related to decreased sensation and circulation to lower extremities.

·       Ineffective Coping related to chronic disease and complex selfcare regimen.