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Assessment Subjective: Objective: (+) crackle in the left side Orthopnea Ascites as evidence by Abdominal girth of 41in.

in. 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 movt 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: Nurses 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 elds.

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: Nurses 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 patients 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 patients 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: Nurses Pocket Guide by Doenges, Moorhouse and MurrImpaired skin integrity, page 487-489

February 22, 2013