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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
ejection
* 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.

Evaluation:
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.

Evaluation:
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
Fatigue
Jaundice (yellowing of skin or eyes)
Darkening of urine
Clay-colored stools
Pain over liver