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Nursing Care Plan

Assessment: Subjective: " Dai ako gaano napapakakan" as verbalized by the patient. Objective: - distended abdomen - ascites - lethargic - decreased albumin level

Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements related to abdominal distention and discomfort Pathophysiology: Planning: After 6 hours of Nursing Intervention the patient will; - ingest nutritional requirements in accordance with his metabolic needs - demonstrate behaviors to regain and maintain appropriate weight - verbalize understanding the importance of maintaining good nutrition Intervention: I- Explain the need for adequate consumption of carbohydrates, fats, protein, vitamins and minerals - good consumption of food nutrients provides energy sources, build tissue, and regulate metabolic process I- Assist patient in identifying low sodium foods - reduces edema and ascites formation I- Arrange to have a high carbohydrate and high protein food

- provides energy, sparring protein for healing I- Elevate head of the bed during meals - Reduces discomfort from abdominal distention and decreases sense of fullness produced by pressure of abdominal contents and ascites on the stomach. D- Offer small but frequent meals and pleasant environment at mealtime - promote positive environment and increase appetite; reduces unpleasant taste. D- Administer Duspatalin, as ordered and administer Lactulose as ordered - Duspatalin treats gastrointestinal spasm by causing them to relax; Lactulose a synthetic sugar used in the treatment of constipation and hepatic encephalopathy, a complication of liver disease. I- Encourage patient to eat meals - encouragement is essential for the patient with anorexia and gastrointestinal discomfort. I- Encourage and help client to maintain good oral hygiene - to enhance appetite because poor hygiene leads to bad odor and taste which diminishes appetite.

Evaluation: Goal Partially Met. As evidenced by the patient is still not able ingesting nutritious food because he still feels bloated. But he understands its importance.

Assessment: Subjective: "Dai ako makahiro ta nanluluya ako" as verbalized by the patient. Objective: - weakness - fatigue - lethargy

- dependent to significant other in doing activities Nursing Diagnosis: Activity Intolerance related to fatigue, lethargy and malaise Planning: After 6 hours of nursing intervention the patient will; - Identify negative factors affecting activity intolerance and eliminate or reduce its effects when possible. - Use identified techniques to enhance activity intolerance - Report decrease in fatigue and eliminates sleep disturbance - Participate willingly in desired activity

Intervention: I- Assess level of activity tolerance and degree of fatigue, lethargy and malaise when performing routine activities of daily activity. - Provides baseline for further assessment and criteria for assessment of effectiveness of intervention I- Assist with activities and hygiene when fatigued. - Promotes exercise and hygiene within patient's level of tolerance I- Encourage rest when fatigued or when abdominal pain or discomfort occurs - conserves energy and protects the liver. D- Provide diet high in carbohydrates with protein intake consistent with liver function - provide calories for energy and protein for healing I- Assist with selection and pacing of desired activities and exercise - stimulates patient's interest in selected activities I- Plan rest periods according to patient's daily schedule. - allow alternating periods of activity and rest and coordinated to reduce periods energy expenditure

Evaluation: Goal Partially Met. The patient is still in malaise but understands techniques in enhancing activity.

Assessment: Subjective: "Narisa ko nalang nagparadakula ang tulak ko" as verbalized by the patient. Objective: - (+) Ascites - weight- 77kg - abdominal girth- 42.5 inches - decreased albumin level - Restlessness Nursing Diagnosis : Fluid Volume Excess related to ascites Planning: After 6 hours of nursing intervention the patient will; - verbalize understanding of dietary and fluid restrictions - demonstrate behaviors to monitor fluid status and recurrence of fluid excess Intervention: D- Restrict sodium and fluid intake - minimizes formation of ascites and edema D- Administer Diuretics: Lasix and Aldactone, as ordered - Potent diuretic (water pill) that is used to eliminate water and salt from the body.

I- Record intake and output accurately - Indicates effectiveness of treatment and adequacy of fluid intake I- Measure and record abdominal girth and weight daily - monitors changes in ascites formation and fluid accumulation I- Explain rationale for sodium and fluid restriction - promotes patient's understanding of restriction and cooperate with it. Evaluation: Goal Partially Met. - The patient verbalizes that he understands the instructions in restricting the foods rich in sodium so he avoids eating such foods - The patients abdominal girth decreases from 42.5 to 41 inches. - But he is still restless and (+) for ascites.

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