NURSING CARE PLAN

PROBLEM: Edema and ascites

NURSING DIAGNOSIS: Fluid Volume Excess related to ascites and edema formation
CAUSE ANALYSIS: Cirrhosis affects water and salt regulation due to portal hypertension, hypoalbuminemia, and hyperaldosteronism. Signs of fluid volume overload and portal hypertension may
develop: ascites, peripheral edema, internal hemorrhoids and varices, and prominent abdominal wall veins. (Medical-Surgical Nursing. Vol. 1. 3rd edition. by Lemone and Burk. pg. 594)
 CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: STO:
Punga ako tiyan as
verbalized by the patient. Within 30 minutes of nursing
interventions, the patient will
verbalized understanding on
proper food selection like low
Objectives: sodium diet.
INDEPENDENT:
1. Assess for jugular vein distention,
measure abdominal girth daily, and check
for peripheral edema.
2. Assess urine specific gravity.
1. Careful assessment is important to detect
fluid shifts.
2. Specific gravity measures the concentration
of urine, an indicator of hydration.
STO:
After 30 minutes of nursing
interventions, the patient verbalized
understanding on proper food
selection like low sodium diet.

Weight (April 18, 3. Provide a low-sodium diet (500 to 2000 3. Excess sodium leads to water retention, and
2010)- 130 lb; mg/day) and restrict fluids as ordered. can increase fluid volume, ascites, and portal
Weight (April 19, LTO: hypertension. LTO:
2010)- 137 lbs;
weight gain- 7 lbs Within 8 hours of giving 4. Record intake and output every 1 to 8 4. Indicates effectiveness of treatment and After 8 hours of giving nursing
nursing interventions, the hours depending on response to adequacy of fluid intake. interventions, the patient was able to
Urine Output (April patient will be able to perceive interventions and on patient acuity. perceive the reason for fluid
19,2010)- 50 ml the reason for fluid restriction restriction and will be able to follow
and will be able to follow 5. Instruct pt. to elevate the extremites 5. This is to reduce swelling. orders appropriately.
Pitting edema on the orders appropriately. affected.
lower and upper
extremities- grade 3
DEPENDENT:
Abdominal girth-
47.1 inches Administer diuretics, Albumin, Aldacton, Promotes excretion of fluid through the kidneys
Furosemide (Lasix) and maintenance of normal fluid and electrolyte
(+) Crackles balance.

Bounding pulse.

REFERENCES: Medical-Surgical Nursing. Vol. 1. 3rd ed. by Lemone and Burk. pg. 594
Brunner & Suddarths Textbook of Medical-Surgical Nursing. Vol. 2, 10th ed. By Smeltzer and Bare. pg. 1109

NURSING CARE PLAN

PROBLEM: Risk for Injury

NURSING DIAGNOSIS: Risk for injury: Bleeding r/t disease process and destruction of Kupffer cells
CAUSE ANALYSIS: Impaired coagulation, esophageal varices and possible gastritis place the client with cirrhosis at significant risk for hemorrhage. Clotting is altered by vitamin K deficiency, impaired
manufacture of coagulation factors II, VII, IX, and X, and increased platelet destruction due to splenomegaly. Also, this is due to destruction of Kupffer cells that are unable to perform phagocytosis
thus, colonic bacteria enter he systemic circulation. (Medical-Surgical Nursing. Vol. 1. 3rd edition. by Lemone and Burk. page 594-595)
 CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective:
Naa lage bun-og ako
kamot, as verbalized by
the patient
Objectives:
-Bruises on both upper
extremities
-WBC: 8-12, increased
(Urinalysis, April 17, 2010)
-PROTHROMBINE TIME :
April 18, 2010
Patient -54.1 sec
Control 14.0 sec
STO: Within eight hours of
rendering health teaching
the patient can identify risk
factors and interventions to
reduce potential for infection
such as maintaining aseptic
technique.
LTO: Within 2 days of
effective nursing
intervention, the pt. would
maintain/demonstrate
improvement in laboratory
values such as absence of
WBC in the urine and blood.
INDEPENDENT:
1. Monitor vital signs; report tachycardia or
hypotension.
2. Institute bleeding precautions.
3. Monitor coagulation studies and platelet
count. Report abnormal results.
4. Carefully monitor the client who has had
bleeding esophageal varices for evidence of
rebleeding: hematemasis, hematochezia
(bright blood in the stool) or tarry stools,
signs of hypovolemic shock.
5. Visitors and health care workers with
active infection are to avoid contact with
patient.
1. Increase pulse and decreasing blood
pressure may indicate hypovolemia due to
hemorrhage.
2. Preventive measures can decrease the risk
for active bleeding.
3. Coagulation studies help determine the risk
for bleeding and the nee for treatment.
4. Rebleeding is common is common following
variceal hemorrhage, especially within the first
week.
5. Reduced contact to infection.
After 8 hours of rendering health
teaching the patient was able to
identify risk factors and interventions
to reduce potential for infection such
as maintaining aseptic technique.
After 2 days of effective nursing
intervention, the pt. was not able to
maintain/demonstrate improvement
in laboratory values such as
absence of WBC in the urine and
blood.

Collaborative:
1. To prevent hemorrhage
1. Administer Vitamin K

REFERENCES: Medical-Surgical Nursing. Vol. 1. 3rd edition. by Lemone and Burk. pg. 594
Brunner & Suddarths Textbook of Medical-Surgical Nursing. Vol. 2, 10th ed. By Smeltzer and Bare. pg. 1110

NURSING CARE PLAN

PROBLEM: Itching
NURSING DIAGNOSIS: Risk for impaired Skin Integrity related to pruritus from jaundice and edema
CAUSE ANALYSIS: Severe jaundice with bile salt deposits on the skin may cause pruritus. Scratching related to the pruritus damages the skin and impairs skin integrity. Malnutrition, particularly
protein deficiency, and edema also increase the risk for tissue breakdown and impaired skin integrity. (Medical-Surgical Nursing. Vol. 1. 3rd edition. by Lemone and Burk. pg. 595)
 CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

STO:
Subjective: Within 8 hours of nursing care,
Katol kaayo ako panit, the patient was able to regain
as verbalized by the integrity of skin surface by
patient application of measures in
minimizing skin itching.
LTO:
Objectives: Within 3 days of nursing care,
-rash the patient will be able to
-reddening of skin describe measures to protect
-single firm lesions the skin. Such as avoiding to
-scaling harsh skin care products,
clean hands, well trimmed
nails.
INDEPENDENT:
1. Use warm water rather than hot water
when bathing.
2. Use measures to prevent dry skin: Apply
an emollient or lubricant as needed to keep
skin moist, avoid soap or preparations with
alcohol, and do not rub the skin.
3. If indicated, apply mittens to the hands to
prevent scratching.
4. Institute measures to prevent skin and
tissue breakdown: Turn at least every 2
hours, use an alternating pressure mattress,
and frequently assess skin condition.
1. Hot water increases pruritus.
2. Dry skin contributes to pruritus.
3. Clients with encephalopathy may not
understand the need to refrain from scratching.
4. Frequent position changes relieve pressure
and promote circulation and tissue oxygenation.
After 8 hours of nursing care, the
patient was not able to regain
integrity application of measures in
minimizing skin itching.
After 3 days of nursing care, the
patient was not able to described
measures to protect the skin. Such
as avoiding to harsh skin care
products.

DEPENDENT:

1. Apply calamine lotion 1. To decrease the itchiness of the skin.

REFERENCES: Medical-Surgical Nursing. Vol. 1. 3rd edition. by Lemone and Burk. pg. 595
Brunner & Suddarths Textbook of Medical-Surgical Nursing. Vol. 2, 10th ed. By Smeltzer and Bare. pg. 1107

NURSING CARE PLAN

PROBLEM: Anorexia
NURSING DIAGNOSIS: Imbalanced Nutrition: Less than Body Requirements related to abdominal fullness and discomfort and anorexia
CAUSE ANALYSIS: The client with cirrhosis is at risk for malnutrition for a number of reasons: possible chronic alcohol use, anorexia, impaired vitamin and mineral absorption and impaired protein
metabolism. (Medical-Surgical Nursing. Vol. 1. 3rd edition. by Lemone and Burk. pg. 595
 CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: STO: INDEPENDENT: STO:

Dili siya ganahan
mukaon as verbalized Within eight hours of
by the SO. initiating nursing interventions
patient will be able to
demonstrate increase appetite
as evidence by consuming
enough diet as indicated.
Objectives:
LTO:
1/3 of food served
consumed (April 18 & 19, Within three days of
2010) initiating nursing interventions
patient will be able
Decreased muscle tone demonstrate behaviors/lifestyle
changes to regain or maintain
Appears weak appropriate weight.
Muscle grade- 2
1. Weigh daily. Instruct to weigh at least
weekly at home.
2. Provide small meals with between meal
snacks.
3. Unless protein is restricted due to
impending hepatic encephalopathy, promote
protein and nutrient intake by providing
nutritional supplements such as Ensure or
Instant Breakfast.
4. Arrange for consultation with a dietitian for
diet planning while hospitalized at home.
5. Provide oral hygiene.
1. Weight is a good indicator of both nutritional
status and fluid balance. Short-term weight
fluctuations tend to reflect fluid balance, while
longer-term changes in weight are more
reflective of nutritional status.
2. A small meal is more appealing for an
anorexic client. Between-meal snacks help
maintain adeuate calorie and nutrient intake.
3. The sodium and protein content of all meals
and snacks must be calculated when
maintaining restrictions of these nutrients.
4. The dietitian can provide detailed
instructions, sample menus, and suggestions
for improving the palatability of the dient and
promoting intake.
After eight hours of initiating
nursing interventions patient, was
able to demonstrate increase
appetite as evidence by consuming
enough fitting diet as indicated.
LTO:
After three days of initiating
nursing interventions, patient was
able to demonstrate
behaviors/lifestyle changes to regain
or maintain appropriate weight.

Collaborative:

1. Administer multivitamins such as:

Essentiale forte Regulates membrane permeability and
improves the exchange of substances between
the intra- and extracellular space. It activates
metabolic function and supports the energy
balance of the liver. It restores enzyme
functions and promotes detoxification of the
liver. Neutral fats and cholesterol are
transformed into transportable forms and led to
their physiological oxidation. Liver cell
regeneration is stimulated and the bile is
stabilized.

Aminoleban Because of their peculiar role in whole-body

nitrogen metabolism and the competitive action
on amino acid transport across the bloodbrain
barrier, branched-chain amino acids (BCAAs)
have been extensively used in subjects with
liver disease to preserve or to restore muscle
mass and to improve hepatic encephalopathy.

GODEX is a multicomponent drug containing

 Mitodex (Godex) Carnitine orotate, adenine HCl,
cyanocobalamin, pyridoxine HCl, and riboflavin
which acts synergistically. GODEX:
1.prevents fat accumulation and protects cell
membrane integrity.
2. provides efficient mitochondrial energy
system.
3. detoxifies acyl groups and ROS.
4.restores elctron balance for greater energy
supply.
5. increases nucleic acid synthesis and mtDNA
copy number for repair of mitochondria

REFERENCES: Medical-Surgical Nursing. Vol. 1. 3rd edition. by Lemone and Burk. pg. 595
Brunner & Suddarths Textbook of Medical-Surgical Nursing. Vol. 2, 10th ed. By Smeltzer and Bare. pg. 1107
 NURSING CARE PLAN

PROBLEM: Body Malaise

NURSING DIAGNOSIS: Activity Intolerance related to fatigue, lethargy and malaise secondary to liver cirrhosis.
CAUSE ANALYSIS: Due to bile salts accumulation in the blood, the decreased bile salts enable to diminished fat emulsification and absorption leading to weight loss and general weakness. Decrease
in strength in muscles in any part of the body can lead to immobilization. Decreased in strength may be due to inefficient circulation of blood to a part of the body. [Medical Surgical Nursing By
Smeltzer and Bare]
 CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

INDEPENDENT:
Subjective: STO: STO:
kahoy kaayo ako Within 4 hours of effective 1. Asses level of activity tolerance and egree 1. Provides baseline for further assessment and After 4 hours of effective nursing
lawas, as verbalized by nursing intervention the patient of fatigue, lethargy and malaise when criteria for assessment of effectiveness of intervention the patient was not able
the patient. will regain normal mobility as performing routine ADLs. interventions. to regain normal mobility as
evidenced by ability to move evidenced by ability to move within
within the physical 2. Assist with activities and hygiene when 2. Promotes exercise and hygiene within the physical environment
environment fatigued. patients level of tolerance.
Objectives:
the patient 3. Encourage rest when fatigued or when 3. Conserves energy and protects the liver. LTO:
appears weak LTO: abdominal pain or discomfort occurs. After 8 hour shift, the patient was
minimized Within 8 hour shift, the not able to maintain/increase
movements patient will maintain/increase 4. Assist with selection and pacing of 4. Stimulates patients interest in selected strength and function of affected or
have limited strength and function of desired activities and exercise. activities. compensatory body parts as
ROM activity affected or compensatory body evidenced by coordination, normal
parts as evidenced by 5. Provide diet high in carbohydrates with 5. Provides calories for energy and protein for ROM, and increased muscle
needs
coordination, normal ROM, protein intake consistent with liver function. healing. strength.
assistance in
and increased muscle
positioning in
strength.
bed
DEPENDENT:
unable to
ambulate 1. Administer suplemental vitamins (A, B 1. To provides additional nutrients.
without complex, C, and K).
assistance
stays in bed
most of the time

REFERENCES: Brunner & Suddarths Textbook of Medical-Surgical Nursing. Vol. 2, 10th ed. By Smeltzer and Bare. pg. 1107

NURSING CARE PLAN

PROBLEM: Edema/Ascites
 CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: STO:
nidako lage ako tiyan After 2 days in giving nursing
as verbalized by the intervention, the patient will be
patient. able to verbalize acceptance of
self in situation, relief of
anxiety and adaptation to
altered body image and will be
able to verbalize
Objectives: understanding of body
-pitting edema grade 3 changes.
-skin rashes
-bruises
LTO:
After 3 days of giving
nursing intervention, the
patient will be able to
recognize and incorporate
body image change into self
concept in accurate manner
without negating self esteem,
and will be able to
acknowledge self as an
individual who has
responsibility to self.
INDEPENDENT:
1. Assess changes in appearance and the
meaning these changes have for patient and
family.
2. Encourage patient to verbalize reactions
and feelings about these changes.
3. Assess patients and familys previous
coping strategies.
4. Assist and encourage patient to maximize
appearance and explore alternatives to
previous sexual and role functions.
5. Assist patient in identifying short-term
goals.
6. Encourage and assist patient in decision
making about care.
7. Identify with patient resources to provide
additional support (counselor, spiritual
advisor).
1. Provides information for assessing impact
ofchanges in appearance, sexual function, and
role on the patient and family.
2. Enables patient to identify and express
concerns; encourages patient and significant
others to share these concerns.
3. Permits encouragement of those coping
strategies that are familiar to patient and have
been effective in the past.
4. Encourages patient to continue safe roles
and functions while encouraging exploration of
alternatives.
5. Accomplishing these goals serves as positive
reinforcement and increases self-esteem.
6. Promotes patients control of life and
improves sense of well-being and self-esteem
7. Assists patient in identifying resources and
accepting assistance from others when
indicated.
STO:
After 2 days of giving nursing
interventions the patient was able
verbalized acceptance of self in
situation relief anxiety and
adaptation to altered body image
and was able verbalized
understanding of body changes.
LTO:
After 3 days the patient was able
to recognized and incorporated body
image into self-concept in accurate
manner without negating self-
esteem and was able to
acknowledge self as an individual
who has responsibility for self.

8. Assist patient in identifying previous 8. Recognition and acknowledgment of the

practices that may have been harmful to self harmful effects of these practices are necessary
(alcohol and drug abuse). for identifying a healthier lifestyle.

NURSING DIAGNOSIS: Disturbed body image related to changes in appearance, sexual dysfunction, and role function
CAUSE ANALYSIS: In liver cirrhosis, increased Na and water retention causes edema due to fluid shift to extravascular compartment leading to edema. Endocrine function is also altered with
increased/elevated androgen and estrogen levels in the blood of male and female, respectively. Common manifestations include gynecomastia, decreased libido, fall of body hair, atrophy of testicles
in male. In female - hirsutism, acne, deepening of voice, and increase virilism. (Medical Surgical Nursing Udan, pp. 333)

REFERENCES: Brunner & Suddarths Textbook of Medical-Surgical Nursing. Vol. 2, 10th ed. By Smeltzer and Bare. pg. 1108-1109

NURSING CARE PLAN

PROBLEM: Abdominal Pain
NURSING DIAGNOSIS: Acute pain and discomfort related to enlarged tender liver and ascites and oversecretion of acid.
CAUSE ANALYSIS: In liver cirrhosis, abdominal pain may be present because of recent, rapid enlargement of the liver, producing tension on the fibrous covering of the liver (Glissons capsule). Later
in the dse the liver decreases in size as scartissue contracts the liver tissue. The liver edge is palpable, is nodular. Also, due to imapired gastrin in the blood causes excessive stimulation of the
stomach parietal cells leading to oversecretion of acid. (Med-Surg Nursing by Bare, pp. 1102)
 CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

STO: INDEPENDENT: STO:

Subjective: Within 1-2 hours of Objective partially met, patient
Pt. may verbalize pain at implementing nursing 1. Maintain bed rest when patient 1. Reduces metabolic demands and protects verbalized pain scale 0f 2/10.
the abdominal area. interventions, patient will be experiences abdominal discomfort. the liver.
P- when respiration and able to verbalize pain relief at
moving a level of from a scale 1/10 2. Observe, record, and report presence and 2. Provides baseline to detect further
Q-stabbing verbalizes feelings of character of pain and discomfort. deterioration of status and to evaluate LTO:
R-whole abdomen reasonable comfort. interventions. After 8 hours of effective nursing
S-6/10 intervention, patient was able to be
T- when moving felt for 3. Reduce sodium and fluid intake if 3. Minimizes further formation of ascites. free from pain as evidenced by
about 2 minute prescribed. stable v/s, absence of muscle
LTO: tension and restlessness.
Within 8 hours of effective 4. Prepare patient and assist with 4. Removal of ascites fluid may decrease
nursing intervention, patient paracentesis. abdominal discomfort.
will be free from pain as
Objectives: evidenced by stable v/s,
-restless absence of muscle tension and DEPENDENT:
-muscle tension present restlessness.
-irritable 5. Administer antispasmodic and sedative 5. Reduces irritability of the gastrointestinal tract
-facial grimace agents as prescribed. and decreases abdominal pain and discomfort.

REFERENCES: Brunner & Suddarths Textbook of Medical-Surgical Nursing. Vol. 2, 10th ed. By Smeltzer and Bare. pg. 1109

NURSING CARE PLAN

PROBLEM: Difficulty of breathing

NURSING DIAGNOSIS: Ineffective breathing pattern related to ascites and restriction of thoracic excursion secondary to ascites, abdominal distention, and fluid in the thoracic cavity
CAUSE ANALYSIS: In liver cirrhosis, portal hypertension causes hepatic shunting due to splenomegaly (impaired RBC destruction) causing excessive RBC lysis as evidenced by decreased RBC in
the serum blood plasma which impairs oxygen and carbon dioxide exchange, thus tachypnea occurs to compensate more oxygen demand and carbon dioxide as stimulator for respiration. (Med-Surg
Nursing by Carol Porth)

CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

 STO:
Subjective: Within 1-2 hours of nursing
lisud kaayo iginhawa, interventions, patient will
as verbalized by the participate in actions to
patient. maximize oxygenation as
evidenced by participating in
deep-breathing exercises,
coughing exercise.
Objectives:
-flaring of nose
-inadequate chest
expansion LTO:
-RR (23-25) Within 3 days of implementing
-presence of adventitious nursing interventions, patient
sounds-crackles will be able experience
-use of accessory muscle maximal pulmonary ventilation
-O2 sat -87-88 and adequate gas exchange
-capillary refill- <3 by absence of pallor, and
difficulty of breathing.
INDEPENDENT:
1. Elevate head of bed to at least 30
degrees.
2. Conserve patients strength by providing
rest periods and assisting with activities.
3. Change position every 2 hours.
DEPENDENT:
4. Assist with paracentesis
a. Explain procedure and its purpose to
patient.
STO:
After 1-2 hours of nursing
1. Reduces abdominal pressure on the interventions, patient was able to
diaphragm and permits fuller thoracic excursion participate in actions to maximize
and lung expansion. oxygenation as evidenced by
participating in deep-breathing
2. Reduces metabolic and oxygen exercises, coughing exercise.
requirements.
3. Promotes expansion and oxygenation of all
areas of the lungs. LTO:
After 3 days of implementing nursing
interventions, patient was not able to
experience maximal pulmonary
4. Paracentesis is performed to remove fluid ventilation and adequate gas
from the abdominal cavities may be frightening exchange by absence of pallor, and
to the patient. difficulty of breathing.
a. Helps obtain patients cooperation with
procedures.

b. Have patient void before paracentesis. b. Prevents inadvertent bladder injury.

c. Support and maintain position during c. Prevents inadvertent organ or tissue injury.
procedure.

d. Record both the amount and the d. Provides record of fluid removed and
character of fluid aspirated. indication of severity of limitation of lung
expansion by fluid.

5. Administer O2 @ 10 l/min 5.To provide adequate oxygen inhalation

6. Administer Salbutamol. 6. to promote bronchodilation

REFERENCES: Brunner & Suddarths Textbook of Medical-Surgical Nursing. Vol. 2, 10th ed. By Smeltzer and Bare. pg. 1111

NURSING CARE PLAN

PROBLEM: Anxiety
NURSING DIAGNOSIS: Anxiety related to threat to or change in health status associated with stress
CAUSE ANALYSIS: Disease is the major cause of psychological disturbances of most individual. It affects the five dimensions yet it is more on psychoaspect of the person. When the individual knows
that he/she is ill the first alteration is the behavioral and followed by the psychological. From time to time the pt. become anxious and deppressed leading to contribution to body stress. Other may not
sleep but others can do cope with it. Reference: General Psychology by Bustos page 35-38.
 CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: STO: INDEPENDENT: STO:

No verbal cues
Within 4 hrs. of rendering
effective nursing interventions
the pt. will be able to display
decrease anxiety state as
evidenced by cooperation and
conversant to the health care
team.
Objectives: LTO:
- restlessness
-increased BP- 140/100 Within 8 hrs. of rendering
-increased HR- 95 effective nursing care the pt.
will be able to be
knowledgeable enough about
on how to develop good
coping skills.
1. Monitor anxiety behavior and relationship 1. When anxiety increases, the abillity to follow After 4 hrs. of rendering effective
to activity, events, people every shift. instruction or cooperation in plan of care nursing interventions the pt.
decreases. Identification of the behavior and displayed decrease anxiety state as
causative factors enhances intervention plans. evidenced by cooperation and
2. Assist the pt. to learn recognizes and 2. Helps identify connection between the conversant to the health care team.
identifies the signs and symptoms of anxiety. precipitating cause and the anxiety experience.
3. Provide calm, none threatening
environment. 3. Conveys calm and helps the pt. focus on LTO:
conversation or activity.
4. Attend the primary physical needs After 8 hrs. of rendering effective
promptly. 4. Conserves the pts energy and allows the pt. nursing care the pt. was
to fucos on coping with and reducing anxiety. knowledgeable enough about on
Failure to attedn physical needs promptly would how to develop good coping skills.
5. Monitor the vital signs per shift. serve to increase anxiety.
5. Assist in determining the effects of anxiety.
6. Assist pt. in developing coping skills. Helps determine pathologic effects of anxiety.
6. Methods that can be used successfully to
decrease anxiety. Allows the pt. to practice and
become comfortable in skills with supporting
environment. Determines what has helped and
determines whether these measures are still
useful.
DEPENDENT:
DEPENDENT:
1. Refer the pt. to a collaborative with
appropriate community resources for care. 1. Support groups can provide ongoing
assistance after discharge.

REFERENCES: Clinical Applications of Nursing Diagnosis by Cox, H. et al pages 456-458

NURSING CARE PLAN

PROBLEM: Tachycardia
NURSING DIAGNOSIS: Altered Tissue Perfusion related to psychological and physical changes associated with fluctuations of peripheral pulse rates
CAUSE ANALYSIS: When the person becomes stressful and anxious the symphathetic nervous system will be stimulated thus increasing the heart rate of the individual. This stimulation is triggered
by the circulating baroreceptors that activate the sympathetic nervous system to increase excitability.
Reference: Medical Surgical Nursing by Ignatavicius and Workman page 929.
 CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: STO:
No subjective cues Within 4 hrs. of rendering
effective nursing interventions
the pt. will be able to take
resting periods to stabilized the
PR and RR.
INDEPENDENT:
1. Monitor the trends in heart rate and blood
pressure.
2. Record skin temperature, color, quantity
and equality of peripheral pulses.
1. Tachycardia is common response to
discomfort and anxiety likewise with pain
perceived by the pt., fluid replacement and
stress.
2. May indicate decrease oxygenation as a
result of diminished cardiac output.
STO:
After 4 hrs. of rendering effective
nursing interventions the pt. was
able to take resting periods to
stabilized the PR and RR.

3. Measure and document input and output. 3. Useful in determining fluid needs or LTO:
identifying fluid excess which compromise
LTO: cardiac output and oxygenation. After 8 hrs. of rendering effective
Objectives: 4. Monitor daily activities. Note pt. response 4. Regular activities and mobility stimulates nursing care the pt. experienced
Within 8 hrs. of rendering to its vital signs. circulation and promotes feeling of well-being. signs of anxiety and fatigue
RR- 23-25 breathes per effective nursing care the pt.
min will be able to experience no 5. Evaluate the presence of physical stress, 5. Excessive emotional reaction can affect vital
PR- 90-95 signs of anxiety and fatigue. anxiety and fatigue. Encourage use of signs of the pt.
Appears weak relaxation technique such as deep
breathing.

6. Monitor output. 6. Reduced in circulatory volume which

negatively affects perfusion.
DEPENDENT:

1. Administer IV fluids as ordered. 1. Maintains adequate circulating volume and

enhance oxygen carrying capacity.
REFERENCES: Clinical Applications of Nursing Diagnosis by Cox, H. et al pages 124-125.

NURSING CARE PLAN

PROBLEM: Crackles
NURSING DIAGNOSIS: Impaired Gas Exchange r/t accumulation of fluid in pleural space secondary to Liver Cirrhosis
CAUSE ANALYSIS: Accumulation of secretion in the lungs will inhibit the transport of oxygen to the cell and carbon dioxide out from the cell thus causing ventilation imbalance.( Med. Surg. Nursing by
S. Smeltzer and B. Bare pp, 468-469)

CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term objective:
No verbal cues After 8 hours of giving effective
nursing intervention and health
teaching, the patient will be able to
know positioning techniques that
improve ventilation.
Objective:
Use of accessory muscles
Labored breathing (shallow
breathing) Long term objective:
RR- 23-25 breathes per min After 3 days of giving effective
O2 sat -87-88 nursing intervention and health
(+) crackles teaching, the patient will demonstrate
improve ventilation as evidence by
blood gases within clients normal
parameters.
6
Reference: Nursing care Plan: Guidelines for individualizing patient car.ed ; M. Doenges, M.F Moorhouse, A. Geissler-Murr.pp.199-200
PROBLEM: Risk for Aspiration
NURSING DIAGNOSIS: Risk for aspiration related to the presence of nasogastric tube
CAUSE ANALYSIS: Aspiration pneumonia occurs when stomach contents or enteral feedings are regurgitated and aspirated, or when an NGT is improperly positioned and feedings are instilled into
the pharynx or the trachea.(Med. Surg. Nursing by S. Smeltzer & B. Bare pp. 993-994)
CUES OBJECTIVES
Subjective:
No Verbal Cues Short term objective:
Independent:
1. Promote good ventilation After 8 hours of giving effective
1. Position client in either
and breathing. nursing intervention and health
semi-fowlers position or side
teaching, the patient was able to
lying position
2. Will promote mucoid or know positioning techniques that
2. Encourage client to cough
sputum excretion from the improve ventilation.
as tolerated.
lungs
3. Monitor respiratory rate,
3. Proper assessment will help
depth, and effort, including
identify early problems.
use of accessory muscles,
nasal flaring, and thoracic or
abdominal breathing.
4. Changes in behavior and
4. Monitor clients behavior
mental status can be early After 3 days of giving effective
and mental status for onset
signs of impaired gas nursing intervention and health
of restlessness, agitation,
exchange teaching, the patient was not able to
confusion
5. Central cyanosis in tongue demonstrate improve ventilation as
5. and in the late stages,
and oral mucosa is evidence by blood gases within
extreme lethargy
indication of serious hypoxia clients normal parameters.
and is a medical
emergency;
6. Peripheral cyanosis seen in
6. Observe for cyanosis in
extremities may not be
skin: note especial color of
serious.
tongue and oral mucous
membrane.
Dependent:
1. To promote enough oxygen
1. Administer oxygen
supply
inhalation appropriately.
2. Administer salbutamol 2. To provide bronchodilation.
NURSING CARE PLAN
NURSING INTERVENTIONS RATIONALE EVALUATION
 After 2days of giving effective nursing
intervention and health teaching, the
patient will be able to strengthen
swallowing reflex when the NGT will
be removed.
Objective:
Appears weak
Use of accessory muscle
Difficulty of breathing
Long term objective:
After the patient will be discharged,
the patient will be able to swallow
foods appropriately and swallowing
impairment will goes back to normal.
Reference: Nursing Diagnosis Handbook: A guide to planning care by: Auckley & Ladwig pp. 116-117
PROBLEM: Lack of information
NURSING DIAGNOSIS: Knowledge Deficit: cause/treatment of condition related to lack of factual information of disease process
CAUSE ANALYSIS: Knowledge deficit is a state which an individual or family does not comprehend, learn or demonstrate knowledge of health care measure necessary to maintain health. Having lack
of information regarding the disease condition, patient cannot make effective decisions about his/her health that results to inability to participate to participate actively and assume responsibility for
much of his/her own care. (Med-Surg by Brunner and Suddarth pg. 46, Fundamentals of Nursing pg. 392)
CUES OBJECTIVES
Independent: 1. X-ray verification of After 2days of giving effective nursing
placement is the only intervention and health teaching, the
1. Check to make sure initial
consistently reliable method patient was not able to strengthen
feeding tube placement was
to detect inadvertment swallowing reflex when the NGT will
confirmed by x-ray,
respiratory placement. be removed.
especially if a small bore
feeding tube is used; keep
2. The auscultatory air
feeding tube securely taped.
insufflation method is often
2. Determine placement of
not reliable in differentiating
feeding tube before each
between gastric or
feeding or every 4 hours if
respiratory placement. pH
continuous feeding. Check
testing can generally predict
pH of aspirate; do not rely
feeding tube position in the After the patient will be discharged,
on air insufflation method.
gastrointestinal tract. the patient was not able to swallow
3. Increased intragastric foods appropriately and swallowing
3. Check for gastric residual at
pressure can result in impairment will goes back to normal.
least every 8 hours and
regurgitation and aspiration.
before feedings; if greater
than 100 ml, follow
institutional protocol on
4. Keeping the clients head
holding feeding.
elevated helps keep food in
4. During feeding, position
stomach and decrease
client with head of bed
incidence of aspiration.
elevated at least 30
degrees, preferably higher;
maintain for 30 to 45
5. It is difficult to keep the
minutes after feeding.
head elevated when turning
5. Stop continual feeding
or moving a client.
temporarily when turning or
6. Laryngeal nerve endings
moving client.
are reduced in the elderly,
6. Carefully check elderly
which diminishes the gag
clients gag reflex and ability
reflex.
to swallow before
NURSING CARE PLAN
NURSING INTERVENTIONS RATIONALE EVALUATION
Subjective:
Wala ko kabalo unsa hinungdan
kung ngano nag ka hepa ko, as
verbalized by the patient.
Objective:
patient asking questions
about her condition
requests for additional
information
inaccurate follow through of
instructions
STO:
After 15 mins of appropriate
health teachings, patient will be able
to verbalize understanding of
condition and potential complication,
individual risk factors.
LTO:
After 2 days of care, patient will
correctly perform necessary
procedures and explain reasons of
action, actively participates in
regimens given to promote wellness.
Independent:
o Assess patient/SO level of
knowledge and
ability/desire to learn.
o Be alert to signs of
avoidance, e.g., changing
subject away from
information being
presented or extremes of
behavior
(withdrawal/euphoria).
o Present information in
varied learning formats,
e.g., programmed books,
audiovisual tapes,
question-and-answer
sessions, group activities.
o Reinforce explanations of
risk factors, dietary/activity
restrictions, medications,
and symptoms requiring
immediate medical
attention.
o Encourage
identification/reduction of
o Necessary for creation of individual After 15 mins of appropriate
instruction plan. Reinforces health teachings, patient was able to
expectation that this will be a verbalize understanding of condition
learning experience. Verbalization and potential complication, individual
identifies misunderstandings and risk factors.
allows for clarification.
o Natural defense
mechanisms, such as
anger or denial of
significance of situation,
can block learning,
affecting patients
response and ability to
assimilate information.
Changing to a less After 2 days of care, patient was not
formal/structured style may able to perform necessary
be more effective until procedures and explain reasons of
patient/SO is ready to action, actively participates in
accept/deal with current regimens given to promote wellness.
situation.
o Using multiple learning
methods enhances
retention of material.
o Provides opportunity for
patient to retain information
and to assume
control/participate in
rehabilitation program.
Note: Routine use of
supplements/herbal
remedies (e.g., ginkgo
biloba, garlic, vitamin E)
can result in alterations in
blood clotting, especially
when anticoagulant/ASA
therapy is prescribed.
o These behaviors/chemicals
have direct adverse effects
 individual risk factors, e.g.,
smoking/alcohol
consumption, obesity.
o Warn against isometric
activity, Valsalva
maneuver, and activities
requiring arms positioned
above head.
o Review programmed
increases in levels of
activity. Educate patient
regarding gradual
resumption of activities,
e.g., walking, work,
recreational and sexual
activity. Provide guidelines
for gradually increasing
activity and instruction
regarding target heart rate
and pulse taking, as
appropriate.
o Identify alternative
activities for bad weather
days, such as measured
walking in house or
shopping mall.
o Review signs/symptoms
requiring reduction in
activity and notification of
healthcare provider.
Differentiate between
increased heart rate that
normally occursduring
various activities and
worsening signs of cardiac
stress (e.g., chest pain,
dyspnea, palpitations,
increased heart rate lasting
more than 15 min after
cessation of activity,
excessive fatigue the
on cardiovascular function
and may impede recovery,
increase risk for
complications.
o These activities greatly
increase cardiac workload
and myocardial oxygen
consumption and may
adversely affect myocardial
contractility/output.
o Gradual increase in activity
increases strength and
prevents overexertion, may
enhance collateral
circulation, and allows
return to normal lifestyle.
Note: Sexual activity can
be safely resumed once
patient can accomplish
activity equivalent to
climbing two flights of
stairs without adverse
cardiac effects.
o Provides for continuing
daily activity program.
o Pulse elevations beyond
established limits,
development of chest pain,
or dyspnea may require
changes in exercise and
medication regimen.
 following day).
o Stress importance of
follow-up care, and identify
community
resources/support groups,
e.g., cardiac rehabilitation
programs, coronary
clubs, smoking cessation
clinics.
o Emphasize importance of
contacting physician if
chest pain, change in
anginal pattern, or other
symptoms recur.
o Stress importance of
reporting development of
fever in association with
diffuse/atypical chest pain
(pleural, pericardial) and
joint pain.
DEPENDENT
o Encourage patient/SO to
share concerns/feelings.
Discuss signs of
pathological depression
versus transient feelings
frequently associated with
major life events.
Recommend seeking
professional help if
depressed feelings persist.
Reference: Nursing Care Plan 6th edition by Doenges, Geissler-Murr, & Moorhouse
o Reinforces that this is an
ongoing/continuing health
problem for which
support/assistance is
available after discharge.
Note: After discharge,
patients encounter
limitations in physical
functioning and often incur
difficulty with emotional,
social, and role functioning
requiring ongoing support.
o Timely
evaluation/intervention
may prevent complications.
o Post-MI complication of
pericardial inflammation
(Dresslers syndrome)
requires further medical
evaluation/intervention.
o Depressed patients have a
greater risk of dying 618
mo following a heart
attack. Timely intervention
may be beneficial. Note:
Selective serotonin
reuptake inhibitors
(SSRIs), e.g., paroxetine
(Paxil), have been found to
be as effective as tricyclic
antidepressants but with
significantly fewer adverse
cardiac complications.