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Preoperative and Post Liver Transplant Nursing Care Plan , Nursing Process

Risk for infection related to surgical procedure

Nursing Intervention:
* Assess vital signs, surgery site , close monitoring of sings and symptoms of r
* Frequent suction as indicated and care of chest tube if present
* check dressing frequently
* Change position every 2 hours
*Monitor urine output hourly ; maintain careful intake and output records.
Weigh daily.*
*Monitor for signs of active bleeding, including excess drainage
*Monitor serum electrolytes and laboratory values related to
blood coagulation, liver function, and renal function.
Monitor neurologic status.*
* Encourage pt. to use spirometer
* Assist pt. to get out of bed
* Encourage pt. to participate in self-care procedure to decrease complication o
f immobility

*Provide discharge teaching:

a. Teach how to reduce risk of infection, and signs of infection
to report.
b. Instruct to recognize and report signs of organ rejection
c. Discuss all medications, including their purpose, schedule,
adverse effects, and potential long-term effects. Stress the
importance of complying with all prescribed medications
and postoperative precautions
Give them written and verbal instruction about how and when to take medication a
nd problem that require consultation
d. Discuss possible changes in body image and psychologic
responses to receiving a transplanted organ

f. Stress importance of continued follow-up with transplant team and primary car
e provider.

Pt. remain free of infection, as evidenced by normal WBC count, temp < 100 F, an
d absence of purulent drainage from incisions.
Nursing Diagnosis:
Anxiety related to surgical procedure as evidenced by verbalization from the pat
ient and patient is noncompliance
Nursing Intervention:
Assess pt. for signs and symptoms of fear and anxiety
Implement measures to reduce anxiety:
a. provide care in a calm, supportive, confident manner
b. orient pt.'s to environment, equipment, and routines;

c. Assure pt. that staff members are nearby; respond to call signal as soon as
possible .
d. Encourage verbalization of fear and anxiety; provide feedback .
e. explain all diagnostic tests .
f. Reinforce physician's explanations and clarify.
g. Initiate preoperative teaching if
h. provide a calm, restful environment
i. Instruct client in relaxation techniques and encourage participation in diver
sional activities
j. Provide information based on current needs of client at a level he/she can un
derstand; encourage questions and clarification of information provided
k. Allow pt. to discuss concerns about future lifestyle and roles
l. provide emotional support and reassurance during the procedure.

The pt .experienced a reduction in fear and anxiety as evidenced by:
1. verbalization of feeling less anxious
2. usual sleep pattern
3. relaxed facial expression and body movements
4. stable vital signs

Signs and Symptoms of Liver Rejection

Fever over 38°C or 100.4°F
Jaundice (yellowing of skin or eyes)
Darkening of urine
Clay-colored stools
Pain over liver