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Nursing - Care Plan of Cirrhosis of the Liver (sample)

Cirrhosis is scarring of the liver and poor liver function. Scar tissue replaces healthy tissue in the liver and prevents the liver from working properly. It is the final phase of chronic liver disease. Cirrhosis progresses slowly, over many years, gradually causing your liver to stop functioning. This is called liver failure.

Common causes of chronic liver disease in the United States are:
  • Hepatitis B or C infection
  • Alcohol abuse

Less common causes include hepatitis B infection, inherited liver diseases, such as haemochromatosis, and a condition called non-alcoholic steatohepatitis (NASH).

Early symptoms include:
  • Fatigue and loss of energy
  • Poor appetite and weight loss
  • Nausea or belly pain
  • Small, red spider-like blood vessels on the skin

In the later stages, symptoms can include jaundice (yellowing of the skin and whites of the eyes), vomiting blood, dark, tarry-looking stools and a build-up of fluid in the legs and abdomen (oedema).

Sample - Care Plan of Cirrhosis of the Liver  

1. Acute Pain : abdominal - upper right quadrant related to the inflammatory process, marked by:

Subjective data:
  • Patient says: stomach pain on the top and feel bloated.

Objective data:
  • Patients seem to hold the upper abdomen on the right.
  • Patients grimace, if feel sick.
  • Tense facial expression.

Long-term goals:
  • Expected to decrease pain

Short-term goals: expected
  • Grimace reduced
  • Calm face expression
  • General condition improved: Respiration: 20 x / min, Temperature: 36 ° C, pulse: 80 x / min, blood pressure: 120/80 mmHg

Intervention:
  • Observation of vital signs.
  • Adjust the position as comfortable as possible.
  • Teach the patient relaxation techniques breathing deeply.
  • Collaboration with the medical team in the delivery of therapy.

Rational:
  • By observing vital signs, expected: to know the progress of the patient.
  • By adjusting the position as comfortable as possible, expected: patient comfort are met.
  • By encouraging deep breathing relaxation techniques patients, are expected: reduce perceived pain patients.
  • Collaborate with medical team in the provision of therapy, expected: the client gets the right patients receive therapy.

Implementation
  • Blood pressure: 130/80 mm Hg, pulse: 82 x / min, respiration: 24 x / min, temperature: 37 ° C
  • Set position as comfortable as possible with the semi-Fowler position.
  • Teach the patient deep breathing relaxation techniques
  • Carry out in collaboration with the medical team, the analgesic drug delivery.

Evaluation:

S: Patients report pain in the upper abdomen, right hand still hurt.
O: Patients still grimacing, epresi face still tense, the general state: still weak, respiration: 24x/menit, temperature: 37 ° C, pulse: 82 x / minute, blood pressure: 130/80mmhg.
A: The problem is not resolved
P: Continue intervention


2. Imbalanced Nutrition: less than body requirements related to anorexia, characterized by:

Subjective data:
  • Patients say nausea and want to vomit

Objective data:
  • Portions are spent, half of the portion of food.
  • The patient looked weak.
  • Weak general condition.

Long-term goals :
  • Patient's nutritional needs are met

Short-term goals.
  • Patients already spent portions available.
  • General condition improved.
Intervention
  • Give small portions but frequently.
  • Serve food in warm and attractive.
  • Collaboration with a team of nutrition, the diet delivery.
Rational:
  • Expected nutrient clients are met.
  • Expected to reduce the patient's nausea and increase appetite.
  • Patients are expected to receive a diet that fits the patient's illness.
Implementation
  • Give small portions but often
  • Serving food in warm and appealing
  • Carry out in collaboration with a team of nutrition, the provision of a diet low in salt and high in calories and high in protein.
Evaluation

S: Patients say they feel nausea and vomiting
O: The general state is weak, limp body of the patient, not eating out
A: The problem is not resolved
P: Continue intervention

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