XII.

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

>To identify the

extent of
deficiency and for
better treatment
plan

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.

XII. 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.
Source:
http://www.medsca

Goals of Care
After 8 hours of
nursing
intervention,
patients
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
>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

Evaluation
After 8 hours
of nursing
intervention,
patients
appetite
improved from
2 tbsp to 5
tbsp per meal.
Goal met.

XII. 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
clients weight

Rationale

Evaluation

XII. Nursing Care Plan

Subjective:
Init ako
pamati
As verbalized by
patient.
Objective:
>warm to touch
>Increase in
body
temperature
above normal
range Temp39.9 degree
celcius
>RR: 25cpm
>HR: 122bpm
>Weakness
observed
>Dry mucous
membranes
>Flushed Skin

Hyperthermia
related to the
infectious
process
Reference:
Fundamentals
of Nursing
-Harry & Perry

Predisposing
Precipitating
- 17 yrs
old
- environmental
-hematologic
stressors
State such as: - emotional
Hgb, Hct,
and physical
RBC, WBC,
stress
And platelet
- poor
appetite
Count.
Inflammation occurs as a
major mechanism defense.

Pathogens enter the system,

and battle against infection
occurs.

Decrease of WBC, RBC, HgB,

Hct, and platelet count in the
hematological report.

Hospitalization

Chills, inability to perspire,

headache, fatigue
Hyperthermia
Source: Medical Surgical
Nursing

After 8
hours of
nurseclient
relationshi
p the
client will
be able to:
1.
Maintain
core body
temperatu
re within
normal
range
2.Demonst
rate
behaviors
to monitor
and
promote
normother
mia

INDEPENDENT:
1. monitor
respirations.

>Hyperventilatio
n may initially
present, but
ventilator effort
may eventually
be important by
hematologic
state.

2. monitor intake
and output.
3. Monitor
laboratory
results.

COLLABORATIVE:
1. Administered
antipyretics,
orally.

2. Provide high
caloric diet.

>To replace GI
losses if there is.
>To note if there
is a change in
any electrolytes
and other
enzymes.

>To have
normothermia.

>To meet
increased
metabolic
demands.

After 8
hours of
nurse-client
interventio
n the client
was able to:
1.Goal met.
Patient was
able to
normalize
and
maintain
the
temperatur
e in normal
range.
2.Goal met.
She was
able to
demonstrat
e behaviors
to promote
normother
mia such as
Tepid
Sponge
Bath.