askep-sirosis1

8/18/2019 ASKEP-SIROSIS1

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Activity intolerance related to fatigue, lethargy, and malaise

Expected Outcomes Nursing Interventions Rationale

• Exhibits increased interest

in activities and events.

• Participates in activitiesand gradually increases

exercise within physical

limits.

• Reports increased

strength and well-being.

• Reports absence of

abdominal pain and

discomfort.

• Plans activities to allow ample periods of rest.

• Taes vitamins as prescribed.

1.Assess level of activity

tolerance and degree o!

!atigue" lethargy" andmalaise when per!orming

routine activities o! daily

living. #activity therapy$

%. &ssist with activities andhygiene when !atigued.# se!lcare assitance$

'. Encourage rest when

fatigued or when

abdominal pain or

discom!ort occurs. #energy

management$

(. &ssist with selection and pacing o!

desired(keinginan)

activities and exercise.

#activity therapy$

). Provide diet high incarbohydrates with protein

intae consistent with liver!unction.#nutrition

management$

*. &dminister supplemental

vitamins(&" + complex" ,"

and -$. .#nutritionmanagement$

. Provides baseline !or

!urther assessment and

criteria !or assessment of

effectiveness of

interventions.

%. Promotes exercise andhygiene within patient/s

level o! tolerance.

'. onserves energy and

protects theliver.

(. 0timulates patient/s

interest in selected

activities.

). Provides calories forenergy and protein !orhealing.

*. Provides additional

nutrients.


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!mbalanced nutrition" less than body re#uirements, related to abdominal distention,

discomfort and anorexia


• Exhibits improved

nutritional status by

increased weight #without

1uid retention$ and improvedlaboratory data.

• 0tates rationale !or dietary

modications.

• Identi2es !oods high in

carbohydrates and within

protein re3uirements

#moderate to high protein in

cirrhosis and hepatitis" low protein in hepatic !ailure$.

• Reports improved appetite.• Participates in oral

hygienemeasures.• Reports increased appetite4identi2es rationale !or smaller"

!re3uent meals.

• 5emonstrates intae of high

calorie diet4 adheres to protein

restriction.

• Identi2es foods and $uids that are nutritious and

permitted on diet.

• Gains weight withoutincreased

edema or ascites !ormation.

• Reports increased appetite and well being.

• Excludes alcohol !rom diet.

• Taes medications !or

gastrointestinal disorders as

.Assess dietary intae and

nutritional status through

diet history and diary"daily

weight measurements" andlaboratory data.

%. Provide diet high in

carbohydrates with

protein intae consistent

with liver !unction.

'. &ssist patient in

identi!ying low-sodium

foods.

(. %levate the head o! the

bed during meals.

). Provide oral hygiene be!ore meals and pleasantenvironment !or meals at

meal time.

*. &ffer smaller" more

!re3uent meals

#* per day$.

6. Encourage patient to eatmeals and supplementary

feedings.

7. Provide attractive meals

and an aesthetically pleasingsetting at meal time.8. Eliminate alcohol.

9. &pply an ice collar for

nausea.

. Identi2es de2cits in

nutritional intae :

ade3uacy o! nutritional

%. Provides calories !orenergy" sparing protein

!or healing.

'. Reduces edema and

ascites !ormation.(. Reduces discom!ort

!rom abdominaldistention and decreases

sense o! !ullness

produced by pressure o!

abdominal contents andascites on the stomach.

). Promotes positive

environment andincreased appetite

*. 5ecreases !eeling o!!ullness6. Encouragement is

essential !or the patient

with anorexia andgastrointestinal

discom!ort.

7. Promotes appetite and

sense o! well;being.8. Eliminates ay reduce incidence

o! nausea.

. Reducesgastrointestinal symptoms

and discom!orts that

decrease the appetite and

interest in !ood.


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prescribed.

• Reports normal gastrointestinal function with

regular bowel !unction.

. &dminister medications

prescribed

!or nausea" vomiting"

diarrhea" or constipation.

%. Encourage increased

$uid intake and exercise i!the patient reports

constipation.

%. Promotes normal

bowel pattern and reducesabdominal discom!ort

and distention.

!mpaired skin integrity related to pruritus from 'aundice and edema

?O&@A 5ecrease potential !or pressure ulcer development4 breas in sin integrity


• Exhibits intact(utuh) skin

without

rednes s,excoriation" or

. &ssess degree of

discomfort related to

pruritus and edema.

. &ssists in determiningappropriate interventions.


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breadown.

• Reports relief frompruritus.

• Exhibits no skin

excoriation !romscratching.

• Bses nondrying soaps

and lotions.0tates rationale

!or use o! nondrying soaps

and lotions.

• Turns sel! periodically.

Exhibits reduced edema of

dependent parts o! the

body.• Exhibits no areas of skin

breakdown.

• Exhibits decreasededema; normal skin

turgor.

%. Note and record degree

of 'aundice and extent of

edema.

'. -eep patients nger

nails short and smooth.

(. Provide !re3uent sincare4 avoid use of soaps

and alcohol-based lotions.

). *assage every % h withemollients4turn every % h.

*. Initiate use o! alternating;

pressure

mattress or low air loss

bed.

6. Recommend avoiding use

o! harsh detergents.

7. Assess skin integrity

every (C7 h. Instruct patient

and !amily in this activity.

8. +estrict sodium as

prescribed.9. Per!orm range of

motion exercises every ( h4

elevate edematousextremities whenever

possible.

%. Provides baseline !or

detecting changes andevaluating e!!ectiveness o!

interventions.

'. Prevents sin excoriation

and in!ection !romscratching.

(. Removes waste products!rom sin while preventing

dryness of skin.

). Promotes mobiliDation o!

edema.*. >inimiDes prolonged

pressure on bony

prominences susceptible to breadown.

6. >ay decrease sinirritation and need !orscratching.

7. Edematous sin andtissue have compromised

nutrient supply and are

vulnerable to pressure and

trauma.8. >inimiDes edema

!ormation.

9. Promotes mobiliDationo! edema.

luid volume excess related to ascites and edema formation

?O&@A Restoration o! normal 1uid volume


• ,onsumes diet low in

sodium and within

prescribed 1uid restriction.

• Takes diuretics ,

potassium" and proteinsupplements as indicated

. +estrict sodium and1uid intae i! prescribed.

%. &dminister diuretics,

potassium" and protein

supplements as prescribed.

. >inimiDes !ormation o!ascites and edema.

%. Promotes excretion o!

1uid through the idneys

and maintenance o! normal1uid and electrolyte


5/9

without

experiencing side e!!ects.• Exhibits increased urine

output.

•Exhibits decreasing

abdominal girth.•Exhibits no rapid increasein weight.

•Identi2es rationale !or

sodium and 1uid restriction.

• 0hows a decrease inascites with decreasedweight.

'. +ecord intake and

output every to 7 h

depending on response to

interventions and on patient

acuity.(. >easure and record

abdominal girth and

weight daily.

). Explain rationale !or

sodium and 1uid restriction.

*. Prepare patient and assist

with paracentesis.

balance.

'. Indicates e!!ectiveness o!treatment and ade3uacy o!

1uid intae.

(. >onitors changes inascites !ormation and 1uid

accumulation.). Promotes patient/s

understanding o! restriction

and cooperation with it.

*. Paracentesis willtemporarily decrease

amount o! ascites present.

!neffective breathing pattern related to ascites and restriction of thoracic excursion

secondary to ascites, abdominal distention, and $uid in the thoracic cavity

?O&@A Improved respiratory status


• Experiences improved

respiratory status.

• Reports decreased

shortness of breath.

• Reports increased strengthand sense o! well;being.

• Exhibits normalrespiratory rate #%C 7min$ with no

adventitious sounds.

• Exhibits full thoracic

excursion with;out shallowrespirations.

• Exhibits normal arterial

blood gases.

• Exhibits ade3uate oxygensaturation by pulse

oximetry.• Experiences absence o!

confusion or cyanosis.

. %levate head o! bed to at

least '9 degrees.

%. ,onserve patient/s

strength by providing restperiods and assisting with

activities.

'. hange position every %

h.

(. &ssist with paracentesisor thoracentesis.

a. %xplain procedure and

its purpose to patient.

b. Fave patient void be!ore

. Reduces abdominal

pressure on the diaphragmand permits !uller thoracic

excursion and lung

expansion.%. Reduces metabolic and

oxygen re3uirements.

'. Promotes expansion and

oxygenation o! all areas o!

the lungs.(. Paracentesis and

thoracentesis #per!ormed to

remove 1uid !rom the

abdominal and thoraciccavities" respectively$ may

be !rightening tothe patient.

a. Felps obtain patient/s

cooperation

with procedures. b. Prevents inadvertent


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paracentesis.

c. 0upport and maintain position during procedure.

d. +ecord both the

amount and the character

of $uid aspirated.

e. Observe for evidence of

coughing, increasing

dyspnea" or pulse rate.

bladder inGury.

c. Prevents inadvertentorgan or tissue inGury.

d. Provides record o! 1uid

removed and indication o!

severity o! limitation o!lung expansion by 1uid.

e. Indicates irritation o! the pleural space and evidence

o! pneumothorax or

hemothorax.

hronic pain and discomfort related to enlarged tender liver and ascites

?O&@A Increased level o! com!ort


• +eports pain and

discom!ort i! present.

• >aintains bed rest and

decreases activity in presence o! pain.

• Taes antispasmodic and

analgesics as indicated andas prescribed.

• Reports decreased pain

and abdominal discom!ort.• Reduces sodium and $uidintae to prescribed levels i!

indicated to treat ascites.• Exhibits decreased

abdominal girth and

appropriate weight changes.

• Reports decreased

discomfort after

paracentesis.

. >aintain bed rest when

patient experiences

abdominal discom!ort.

%. &dminister

antispasmodic and

analgesic agents as

prescribed.

'. Observe" record" and

report presence andcharacter of pain and dis-

comfort.

(. +educe sodium and

$uid intake i! prescribed.

). Prepare patient and assist

with paracentesis.

*. Encourage the use o!

distracting activities such as

music" reading or

meditation.

. Reduces metabolic

demands and protects the

liver.

%. Reduces irritability o! thegastrointestinal tract and

decreases abdominal pain

and discom!ort.'. Provides baseline to

detect !urther

deterioration o! status and toevaluate interventions.

(. >inimiDes !urther

!ormation o! ascites.). Removal o! ascites 1uid

may decrease abdominal

discom!ort.

*. 5istraction may limit the perception o! pain.


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+isk for acute confusion

?O&@A Improved mental status4 ability to cope with cognitive and behavioral changes


• &dheres to protein

restriction.

• 5emonstrates an interestin events and activities in

environment.

• 5emonstrates normal

attention span.

• Hollows and participates inconversation appropriately.

• !s oriented to

person,place, and time.• Remains in bed when

indicated.

• Reports no urinary orfecal

incontinence.

• Experiences no seiDures.• o neurological or

respiratory depression.

• 5evelops no cognitive

impairments but i! theydevelop they are 3uicly

identi2ed and treated

enhancing the potential o!

recovery.• Patient and !amily

describe ade#uate!eelings o! coping and

lowered anxiety. They

demonstrate ability to listen

and to make decisions as

able.

• Patient and !amily

communicate their

feelings and their needs in

a secure

and caring environment.

.+estrict protein,

prescribe for transient

period%. ?ive !re3uent" small!eedings o! carbohydrates.

'. Protect !rom in!ection.

(. -eep environment warm

and dra!t;!ree.

). Pad the side rails o! bed.

*. @imit visitors.

6. Provide care!ul nursing

surveillance to ensure

patient/s sa!ety.

7. &void opioids and barbiturates.

8. &waen at intervals

#every %C( h$ to assess

cognitive status.

9. Identi!y subtle changes

in behavior or sleepCwae pattern #consistent sta!!

caring !or the patient

enhances this assessment as

. Reduces source o!ammonia

%. Promotes consumption o! ade3uate carbohydrates !orenergy re3uirements and

spares protein !rom

breadown !or energy.

'. >inimiDes ris !or !urther increase in metabolic

re3uirements.

(. >inimiDes shivering"which would increase

metabolic re3uirements.

). Provides protection !orthe patient should hepatic

coma and seiDure activity

occur.*. >inimiDes patient/s

activity and metabolic

re3uirements.

6. Provides closemonitoring o! new

symptoms and minimiDes

trauma to the con!used

patient.7. Prevents masing o!

symptoms o! hepatic comaand prevents drug overdose

secondary to reduced ability

o! the damaged liver to

metaboliDe opioids and barbiturates. Prevents

respiratory depression.

8. Provides stimulation tothe patient and opportunity

!or observing the patient/s

level o! consciousness.9. These changes may

herald worsening o!

encephalopathy which re;3uires rapid intervention

including medication.


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they become !amiliar with

patient/s baseline$.. &ssess handwriting or

drawing sill as indication

o! cognitive ability.

%. Encourage patient and!amily to participate in

therapeutic strategies toenhance coping with

episodes o! mental

deterioration.

'. Encourage patient and!amily to discuss !eeling o!

!ear" powerlessness

or emotional distress relatedto patient/s mental

deterioration.

%. Promoting activitiessuch as listening

to music" relaxationtechni3ues or preillness

coping strategies can reduce

anxiety.

'. &ctively listeningdemonstrates caring and

concern.

+isk for imbalanced body temperature" hyperthermia related to in$ammatory

process of cirrhosis

?O&@A >aintenance o! normal body temperature" !ree !rom in!ection


• Exhibits normal

temperature and reports

absence o! chills or

sweating.• 5emonstrates ade#uate

intake of $uids.

• Exhibits no evidence o!

local or systemic infection.

• 5evelops no nosocomialinfections related to

invasive procedureslines.

. +ecord temperature

regularly #every ( h$.

%. Encourage $uid intake

.'. &pply cool sponges or ice

bag !or elevated

temperature.

(. &dminister antibiotics as prescribed.

). &void exposure to

infections.

*. -eep patient at restwhile temperature is

elevated.

. Assess !or abdominal

. Provides baseline todetect !ever and to evaluate

interventions.

%. ,orrects 1uid loss !rom perspiration and !ever and

increases patient/s level o!

com!ort.'. Promotes reduction o!

!ever and increases patient/s

com!ort.

(. Ensures appropriateserum concentration o!

antibiotics to treat in!ection.

). >inimiDes ris o! !urther

in!ection and !urtherincreases in body

temperature and metabolicrate.

*. Reduces metabolic rate.

6. >ay occur with bacterial peritonitis.


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pain" tenderness.

7. Bse sterile techni#ue !or all invasive procedures.

7. >any evidence;based

practice guidelines #!orexample central venous

catheter care$ recommend

the use o! sterile techni3ue

to prevent nosocomialin!ections.

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