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1. Fluid Volume excess related to compromised regulatory mechanism 2. Impaired skin integrity related to altered circulation 3. Activity intolerance related to fatigue
RATIONALE OBJECTIVES Short Term: NSG. INTERVENTION Independent: RATIONALE EVALUATION Short Term:
ASSESSMENT Subjective: Namamanas yung katawan ko, dahil yan sa problema ko sa liver. as verbalized by the patient
Objective: Pallor Edema (Upper & Lower extremities) Orthopnea Rapid weight gain Restlessness and anxious Weak in appearance
S - As manifested by: Namamanas yung katawan ko, dahil yan sa problema ko sa liver. as verbalized by the patient
A liver dysfunction causes cell destruction and fibrosis (scarring) of hepatic tissue. Fibrosis alters normal liver structure and vasculature, impairing blood and lymph flow and resulting in hepatic insufficiency and hypertension in the portal vein. and this may lead to hepatic encephalopathy thus, the bodys regulatory function is
1. Help patient into a position that aids breathing such as fowlers or semi fowlers position
After 1 hour of nursing intervention the patient was able to: Lists signs and symptoms that
1. Describe signs and symptoms that require medical treatment & demonstrate skill in selecting permitted foods such as low in sodium
require medical attention & plans own menu and selects food low in sodium
3. Weigh patient at the 2. Tolerate restricted intake with no emotional discomfort. same time and weighing scale each day
Long term:
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1. Fluid Volume excess related to compromised regulatory mechanism 2. Impaired skin integrity related to altered circulation 3. Activity intolerance related to fatigue
patient will be able to: edema especially in dependent 1. Assist with activities of daily living without undue fatigue & maintain desirable daily fluid intake 1. Administer diuretics as prescribed by the 2. Stabilized fluid volume and normal body function as evidenced by: 2. Maintain the patient on sodium and water restricted as (-) Palor Decreased edema (Upper & Lower extremities) (-) Orthopnea Normal weight gain Absence of restlessness and anxious Not weak in appearance Collaborative: 1. Administer oxygen as ordered. To enhance arterial blood oxygenation (-) Pallor Absence of restlessness and anxious Not weak in appearance GOAL: partially met ordered To reduce excess fluid and prevent reaccumulations - Stabilized normal body function as evidenced by: physician Promotes water and sodium excretion. Dependent: areas After 6 hours of nursing intervention the client was able to: - Performed daily living without undue fatigue while assisting & maintained desirable daily fluid intake Long term:
altered and will not be able to regulate body fluids, patient may manifest edema and increase in weight gain.
1. Fluid Volume excess related to compromised regulatory mechanism 2. Impaired skin integrity related to altered circulation 3. Activity intolerance related to fatigue