3rd Year 2nd Sem Part 2 [Autosaved]

8/13/2019 3rd Year 2nd Sem Part 2 [Autosaved]

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LIVER CIRRHOSIS ACUTE ANEMIA

SECONDARY TOUPPER GASTROINTESTINAL BLEEDING

In partial fulfillment of the requirements in NURS65b Medical Surgical Nursing

Submitted to the level III Clinical Instructors of the College of Nursing,

Cavite State University, Indang, Cavite

Presented by:

BSN Level III/Group2

Al-ghorani, Areej S.

Dimaranan, Zaira Joy D.

Foliente, Jayson P.Jaleco, Cristy Belle D.

Losoloso, Bethlehem

Marqueda, Jessa

Redruco, Nheafe Reden

Salamatin, Anna Marie L.

Sarabia, Rachelline

Trupel, Janah Nicole


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ABSTRACT

We, BSN 3 section 1, group 2 chose Liver Cirrhosis, AcuteAnemia secondary to UGIB as our case for the case presentationbecause this is the patient who had the most significant disease outof all the patients that we handled in GEAMH medical ward during

our threeday shift. This patient is challenging for us because weneed deeper understanding and proper management in order toprovide a safe and quality nursing care.

The purpose of this case study is to learn the disease process,its management, medications and treatment. Here is a briefintroduction and overview of what Liver cirrhosisis all about.

Cirrhosis is a complication of many liver diseasesthat ischaracterized by abnormal structure and function of the liver. Thediseases that lead to cirrhosis do so because they injure and killliver cells and the inflammation and repair that is associated withthe dying liver cells causes scar tissue to form.
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The liver cells that do not die multiply in an attempt toreplace the cells that have died. This results in clustersof newly-formed liver cells (regenerative nodules)

within the scar tissue. There are many causes ofcirrhosis; they include chemicals (such as alcohol, fat,and certain medications), viruses, toxic metals (such asiron and copper that accumulate in the liver as a result

of geneticdiseases), and autoimmuneliver diseaseinwhich the body's immune systemattacks the liver.Patients with cirrhosis may have few or no symptomsand signs of liver disease. Some of the symptoms may

be nonspecific, that is, they don't suggest that the liveris their cause. Some of the more common symptomsand signs of cirrhosis include: Yellowing of the skin(jaundice) due to the accumulation of bilirubinin
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the blood, Fatigue, Weakness, Loss of appetite, Itching, and Easy

bruisingand bleeding from decreased production of blood clotting

factors by the diseased liver.

Alcohol is a very common cause of cirrhosis, particularly in the

Western world. The development of cirrhosis depends upon the

amount and regularity of alcohol intake. Chronic, high levels of

alcohol consumption injure liver cells. Thirty percent of individuals

who drink daily at least eight to sixteen ounces of hard liquor or the

equivalent for fifteen or more years will develop cirrhosis. Alcohol

causes a range of liver diseases; from simple and uncomplicated fatty

liver(steatosis), to the more serious fatty liver with inflammation

(steatohepatitisor alcoholic hepatitis), to cirrhosis. Our patient manifested some of the symptoms of Liver cirrhosis

specifically bleeding. He had been excessively drinking alcoholic

beverages which lead to his condition. His condition will be further

evaluated and assessed as we go along in this case study.
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Initials of the client: R.R.A.

Address: 1B Malagasang Imus Cavite Date of Interview: March 13, 2013 4:00 p.m.

Age: 49 years old Primary Informant: R.R.A.

Birth date: June 20, 1963 Other Data Sources: Patients Chart

Birth Place: Pabella Sta. Cruz Blood Type: O Rh(+)

Gender: Male Civil Status: Single

Religion: Roman Catholic

Highest Educational Attainment: High School Graduate

Current Occupation: Pedicab Driver

Monthly Family Income/Budget: pesos

Everyday Income: Php250-Php300

Income allotment: * Electric bills- Php500-Php700

* Water bills- Php150-Php250

* Food Allowance-Php500-Php1000

*Everyday Expenses- Php200-Php250

Usual Source of Medical Care: Hospital check-ups

Medical Support: Philhealth


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March 9, 2013, 8:35 in the evening patient

R.R.A. was admitted in General EmilioAguinaldo Hospital with his brother as a new

patient due to passing bloody stools and

abdominal pain.


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January 2010, patient was first admitted in Philippine GeneralHospital due to abdominal pain. He was diagnosed with a liverproblem. June 2010, patient had a fever and experiencedrecurrent abdominal pain and bloated stomach, but did notconsult any medical advice and care. He did not visit followup check up. He stayed at home until his stomach subsides.March 2013, a week prior to hospitalization R.R.A. drank

alcohol. 2 days PTA patient had abdominal pain. 1 day PTA, patient had

continuous abdominal pain associated with bloody stools. Hewas sent to the emergency room of GEAMH at 8:35 pm onMarch 9, 2013.


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PAST MEDICAL HISTORY

The patient does not have any serious childhood diseases except formeasles; he also had coughs and colds like any other child.According to thepatient, he had complete immunizations when he was a child. He already had 1dose of Tetanus toxoid due to his current accident. The patient has no knownallergies.

February 7, 2013, at exactly 7:00 a.m. he was hit and run by a motor vehiclewith slight lesions on his extremities and does not go to hospitals instead he stayedat home and rested there with his mother taking care of him. March 3, 2013 in theevening, while R.R.A. is drunk and riding his bicycle, the patient had an accidentand fell, and hit his head. The patient was sent to General Emilio AguinaldoHospital for treatment.

He was first hospitalized at Philippine General Hospital on June, 2010 and

was diagnosed with Liver dysfunction. Second hospitalization was at GeneralEmilio Aguinaldo Hospital on March 9, 2013 due to liver Cirrhosis. The patient hadnot undergone any operations and surgeries as of now. The clients medication areas follows: Vit. K, Tranexamic Acid, Rebamipide, Moriamin forte-calciumpantothenic, Livoline, albumin, furosemide, lactulose and omeprazole.


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I. Health PerceptionHealth ManagementPattern

II. Nutritional Metabolic Pattern III. Elimination Pattern

IV. Activity Exercise Pattern

V. SleepRest Pattern

VI. Cognitive Perceptual Pattern

VII. Self- Perception Pattern

VIII. Role Relationship Pattern

IX. Coping Stress Pattern

X. Value Belief Pattern


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I. Health PerceptionHealth

Management Pattern

Patient R.R.A. perceives health as important part in his life and said

that he loves to live so also as life. Prior to admission, he believes that

he is in good health and that he has good quality of resistance. He

does exercises like biking every morning for almost 30 minutes and

eating healthy foods in maintaining a healthy lifestyle. He has noknown allergies so far. And when he had illness, he drinks medicine

like Bioflu and Biogesic. He said that taking those medicines are

helpful enough to treat his illness. R.R.A. does not use any herbal

medicines since it is not available in their place. He started smokingsince high school at the age of 13, according to him it is because of

peer pressure. Since then, he can consumed 1 pack of cigarette per

day. He also said that he can drink a case of alcohol by himself. He

was circumcised at the age of 12 years old when he was on Grade 6.


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Upon hospitalization, patient still perceiveshealth as an important part of life. He is awarethat drinking alcohol and smoking cigarettes isnot a healthy lifestyle, but since he was

influenced and addicted with it, he couldnt resistfrom taking such. He is now taking too manymedications to keep him healthy and to preventfurther complications on his illness. He said that

he wants to go home to do those past activitiesthat he is doing before and is complaining offeeling of boredom.


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II. Nutritional Metabolic Pattern

The patient usually eats rice, vegetables, meat and sea foods.

Prior to admission the last food that he ate was sardines and 2cups of rice. He loves to eat and his favorite dishes are

sinampalukang manok, calderetang spare ribs and pancit

palabok. He also stated that he ate 6 meals and drinks 6 liters

of water a day. He does not take any supplements or vitamins.

He used to weigh 65kgs. before but now that he was

hospitalized he thinks that he lost some of his weight. He

does not experience any discomfort or problems in

swallowing. Patient R.R.A is ectomorph. He was on NPO for 3

and half days and after that he was ordered to have a cleardiet. He only got his nutrients from the dextrose that was put

in to him.


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III. Elimination Pattern

Prior to hospitalization, R.R.A. usually defecates every morning witha firm, brownish in color feces. And has no problem in controlling

his bowel and has no discomfort in defecating. He eliminates urine

several times a day, usually yellowish in color depending on the

amount of fluids he takes. Has no problem in controlling and

eliminating his urine. Does not lose bowels and urine when he does

not want to. Has no excess perspiration and body odor. There is no

body cavity drainage attached to the patient. The day before his

admission, he experienced passing bloody stools.

Upon hospitalization, patient R.R.A. has difficulty in passing stoolsthats why he was ordered to be given laxatives and suppositories

to help him defecate. He only defecated 2 times since admission.

Because the client is in NPO so we can expect that he has a hard

stool.


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IV. Activity Exercise Pattern

According to patient R.R.A. he has sufficientenergy enough for his desired activities athome and at his work. He is a very active

person back then that he used to bike andwork for his parents. His means of exercise isthrough biking for almost 30 minutes everyday. He spends his spare time by staying with

his friends house and chatting with them. Heis also fond of drinking alcohol and smokingcigarettes with his friends.


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KATZ Index

Act iv i t ies Independence = 1 pt . Dependence = 0 pt .

Bathing 1

Dressing 1

Toileting 1

Transferring 1

Continence 1

Feeding 1

Total Points: 6

The table above shows that patient can do most of the activities of daily

living. He is independent to his caregiver or significant other when it comes

to moving or doing simple activities such as transferring, toileting and

feeding before and during hospitalization.


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V. SleepRest Pattern

Patient R.R.A said that he usually goes to sleep at 12midnight and wakes up at 7am and he feels rested andready for daily activities. According to him he does nothave any problems in sleeping. He does not snore. He

also added that he frequently had dreamt of being fell.He sometimes wakes up at dawn just to void.

Upon hospitalization the patient said that he is notgetting his usual sleeping pattern like before. Thepatient cant sleep well because of the humid

temperature at the hospital and also he is unfamiliarwith his surroundings that is why he feels not fullyrested in the morning. He does not use any sleepingaids to promote sleep.


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VI. Cognitive Perceptual Pattern

The patient complains of having pricking pain in hisright abdomen. That occurs after he had drunk againalcohol that made his stomach bloated. He scored it 8out of 10 and rests seems to help to alleviate the pain.

As signs of aging, he is wearing eye glasses because hecouldnt read words and phrases 12 inches away fromhim. He doesnt have problems in hearing, smellingand his sense of touch. He said that he has a goodmemory with regards with dates. And is aware of the

current events and issues in his country. He has noproblems in concentration. And has no learningdisability. He learns best through personal experiences.


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VII. Self- Perception Pattern

As stated by the patient he is a joyful person he lovesto make people laugh. And most of the time feels goodabout his self. His vocabulary in life is that if he thinkshe can do it he will probably make more than of it.

When he was a child he likes to be outside their houseand play with other children. He said that he is kindand approachable person. When he got problems hetried to calm his self and he thinks optimistically. Hesaid that as soon as he get discharge he will find a work

and will spends most of his time with his family notwith his friends. He thinks that sometimes he get alittle bit odd with people but he assure that he will notharm any of his family.


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VIII. Role Relationship Pattern

According to the patient his family was always mad at himbecause of his consistent vice of drinking alcohol. He also added

that he take drugs before. He lived with his mother and father

because he is still single. And they have a nuclear type of a

family. He is not married yet and is not planning to have

marriage. In his hospitalization right now, her sister and other

siblings are the ones managing the expenses in the hospital.

When he has problems he asks for the help of his older sister

and his friends. He solved his and their familys problem by

talking over with it. He thinks that his mother doesnt like himat all. The client wanted to go home because he feels lonely and

he wished to see his parents. He thinks that he cant court any

girls anymore because of his age. He does not feel isolated from

his neighborhood but misjudge because of his vices.


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IX. Coping Stress Pattern

R.R.A. has someone with him whom he cantalk to but there are times that he just wantedto be alone to think. He likes to help his family

in terms of financial needs. He said that nowhis family is always there by his side tosupport him. The patient never thought ofcommitting suicide because he enjoys life.

When he is stressed he just finds a placewhere he can think and also eat the foods thathe likes.


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X. Value Belief Pattern

Generally, patient gets those things he wantssince he is earning money by himself. Mostimportant part of his life is his parents. The

patient is a Catholic. According to him when hegot sick he always prays but after he recovered hewill not do the usual thing he do when he is sickand he admits that. Now he realized the

importance of having God in our life and weshould always have a strong faith to God. Atpresent he prays before going to sleep.

PHYSICAL


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PHYSICALEXAMINATION


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DI GNOSTIC TEST


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Patient Initial: R.R.A

Age: 49 y/o

Diagnosis: Liver Cirrhosis, Acute Anemia 2oto UGIB

HEMATOLOGY REPORT

EXAM DATE; 3/09/2013

3:05 pmTEST RESULT UNIT REFERENCES

WHITE BLOOD CELLS

RED BLOOD CELLS

HEMOGLOBIN

HEMATOCRIT

MCV

MCH

MCHC

PLATELET

Neutrophil (%)

Lymphocytes (%)

Monocytes (%)

Eosinophils (%)

Basophils (%)

RDM CV

MPV

9.10

2.37

75.0

20.9

88.2

31.6

35.9152

73.4

16.0

8.0

2.4

0.2

15.1

10.3

10^3/uL

10^6/uL

G/L

%

fL

pg

g/dL10^3/uL

%

%

%

%

%

%

fL

5.010.0

M 4.7-6.1 F 4.05.5

M 135180 F 120;.160

M 42.052.0 F37.047.0

M 80 -94 F 81-99

27.031.0

33.037.0150450

50.070.0

25.040.0

3.011.0

1.04.0

0.01.0

11.514.5

7.211.1


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March 10

TIME RECEIVED: 5:00 AM

TIME FINISHED: 9:30 AMCLINICAL CHEMISTRY

COBAS INTEGRA 400 PLUS Generated Result

Test Result Reference Ranges

GLUCOSE (FASTING) 5.42 4.115.89 mmol/L

CHOLESTEROL 2.67 Up to 5.2 mmol/L

TRIGLYCERIDES 0.25 Up to 2.3 mmol/L

HDL 0.986 Mgreater than 1.45

mmol/L

Fgreater than 1.68mmol/L

LDL 1.6 Less than 2.59 mmol/L

VLDL 0.11 Less than 1.04 mmo/L

ALK. PHOS. 157.4 M40 -129 U/LF35104 U/L


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EXAM DATE; 3/11/2013

11: 36 amTEST RESULT UNIT REFERENCES

WHITE BLOOD CELLSRED BLOOD CELLS

HEMOGLOBIN

HEMATOCRIT

MCV

MCH

MCHC

PLATELET

Neutrophil (%)

Lymphocytes (%)

Monocytes (%)

Eosinophils (%)

Basophils (%)

RDM CVMPV

RETICULOCYTE

COUNT

ERTHROCYTE

SEDIMENTATION

RATE

CLOTTING TIMEBLEDDING TIME

4.013.11

98.0

29.0

93.2

31.5

33.8

228

62.9

23.2

9.0

4.7

0.2

16.110.0

10^3/uL10^6/uL

G/L

%

fL

pg

g/dL

10^3/uL

%

%

%

%

%

%fL

%

MM/HR

MIN

MIN

5.010.0M 4.7-6.1 F 4.05.5

M 135180 F 120160

M 42.052.0 F37.0

47.0

M 80 -94 F 81-99

27.031.0

33.037.0

150450

50.070.0

25.040.0

3.011.0

1.04.0

0.01.011.514.5

7.211.1

ADULT 1-2 INFANT 4-8

M 010 F 0-20

24

24

CLINICAL CHEMISTRY


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COBAS INTEGRA 400 PLUS Generated ResultaA

Test Result Reference Ranges

GLUCOSE 5.21 4.115.89 mmol/L

CHOLESTEROL 3.21 Up to 5.2 mmol/L

TRIGLYCERIDES 0.41 Up to 2.3 mmol/LHDL 1.089 Mgreater than 1.45 mmol/L

Fgreater than 1.68 mmol/L

LDL 1.9 Less than 2.59 mmol/L

VLDL 0.19 Less than 1.04 mmo/L

SGOT (AST) 70.2 Mup to 40 U/L

Fup to 32 U/L

SGPT (ALT) 33.0 Mup to 41 U/L

Fup to 33 U/L

ALK. PHOS. 131.4 M40 -129 U/L

F35104 U/L

T. PROTEIN 66.60 6483 g/LALBUMIN 51.23 3552 g/L

GLOBULIN 15.41 2335 g/L

A/G Ratio 3.3 1.12.5 g/L

T. BILIRUBIN 12.70 Less than 17.0 umol/L

D. BILIRUBIN 6.64 03.4 umol/LIND. BILIRUBIN 6.02 1.710.1 umol/L


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DATE: MARCH 13 2013

TIME RECEIVED: 6AM

TIME RELEASED: 7:40AM

CLINICAL CHEMISTRY

COBAS INTEGRA 400 PLUS Generated Result

Test Result Reference Range

T. PROTEIN 27.3 6483 g/L

ALBUMIN 6.49 3552 g/L

GLOBULIN 20.81 2335 g/L

A/G Ratio 0.31 1.12.5 g/L


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N TOMY andPHYSIOLOGY


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P THOPHYSIOLOGY


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DRUG STUDY


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NURSING CARE PLAN

Prioritization of the problem

Actual problem

1. Abdominal Pain

2. Elevated blood pressure

3. Poor hygiene

4. Disturbed sleep pattern

5. Impaired Skin Integrity

6. Impaired Dentition

Potential Problem

1. Risk for Imbalanced Nutrition: less than body requirements

2. Risk for bleeding


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NURISNG CARE PLAN: Acute PainAssessment Diagnosis Planning

Subjective Data:

Sumasakit yung bandang dito ko.

Kumikirot na parang tumitibok

ganun.

Objective Data:

Vital signs of:

T: 36.9

PR: 78

RR: 20

BP: 160/100

(+) mild pricking pain @ Right upper

quadrant of abdomen

Pain scale of 4

out of 10 with 10 as severely painful.

Hard to palpate abdomen

(+) facial grimace

(+) restless

Acute pain

related to

splenomegaly

and liver

inflammation as

evidenced by

hard to palapate

abdomen, mild

pricking pain @

right upper

quadrant of

abdomen,

restlessness and

irritability

secondary to

liver cirrhosis.

Short term:

After 2 hours of nursing intervention,

the patient should have decreased

level of pain from 4/10 to at least 1

2/10, and should have lesser signs of

irritability, facial grimace and

restlessness.

Long Term:

After nursing intervention, the patient

should have understood the

techniques and methods that can be

done in order to reduce pain, and to

maintain and practice the relaxation

methods used at times of discomfort.

Intervention Rationale Evaluation


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te e t o at o a e a uat o

Independent Nursing intervention:

1. Introduced self and established rapport

with the patient.

2. Monitored and recorded vital signs

3. Assessed level of pain, location, andcharacteristic.

4. Positioned the patient in a comfortable

position

5. Instructed the patient to do deep

breathing exercises when in pain.

6. Rendered health teaching about some of

the relaxation methods that can be used

to lessen pain.

Dependent Nursing intervention:

1. Assisted during giving of medications for

pain.

Collaborated Nursing intervention

1. Advised the guardian to help the patient

at times of pain and to always be at bed

side.

2. Instructed the guardian to immediately

report any untoward signs and symptoms.

- To gain trust from the patient

- For base line data.

- Assessment of pain for

additional data

- To promote comfort and lessen

pain sensation.

- In order for the patient not to

feel too much pain at times of

sensation.

- For the patient to know what to

do at times of pain, and to

control pain sensation.

- To lessen pain and promote pain

relief to the patient.

- Presence and care of a guardiancan help lessen the pain felt by

the patient.

- To prevent other complications

and to respond immediately to

the problem before it worsens.

Goal Met

After nursing

intervention, the

patients pain scale

lowered from 4 out

of 10 to 2 out of 10.

NURISNG CARE PLAN El d


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NURISNG CARE PLAN: Elevated

Blood Pressure

Assessment Diagnosis PlanningSubjective Data:

Wala akong nararamdaman, sadyang mataas

lang talaga BP ko.

Objective Data:

Blood pressure recordings:03-12-13 (PM)

3:00: 160/100

5:00: 150/90

03-13-13 (PM)

3:00: 140/90

5:00: 130/80

(+) mild, pricking pain @ right upper

abdomen

Pain scale of 4 out of 10 with 10 as highest.

Medication of Furosemide for management

of hypertension.

Decreased cardiac

output related to

liver inflammation

and pain as

evidenced byelevated blood

pressure of 160/100

and pain at right

upper abdomen

secondary to livercirrhosis.

Short term:

After 2 hours of nursing

intervention, the patients

blood pressure should have

decreased from 160/100 toat least 130/90 mmHg.

Long Term:

After nursing intervention,

thepatientsblood pressure

should have normalizedfrom 150/100 to 120/80,

and should have

maintained normal blood

pressure range.

I ntervention Rationale Goal Met


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I ntervention Rationale Goal MetIndependent Nursing intervention:

1. Established rapport with the

patient.

2. Monitored and recorded vitalsigns

3. Monitored blood pressure every 2

hours.

4. Provided comfort to the patient

5. Advised patient to rest.6. Instructed patient to sit down and

avoid walking and getting up from

the bed frequently.


1. Advised guardians to removestressors and any factors that may

affect the patients blood pressure

range.

2. Instructed the guardians to report

any untoward signs and

symptoms.

- To gain trust from the

patient

- For baseline data- For further

assessment of px

condition.

- To promote relief and

comfort- To lessen the factors

that may contribute to

the elevation of blood

pressure.

- To prevent further

complications and to

respond to the

problem immediately.

After nursing

intervention, the

patients bloodpressure decreased

from 160/100 to

130/80 mmHg.


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NURISNG CARE PLAN: Poor HygieneAssessment Diagnosis Planning

Subjective Data:Limang na araw na akong

di naliligo, ambaho ko na.

Objective Data:

(+) dry skin

(+) foul breath odor(+) dirty nails on feet

(+) oily hair

(+)tooth cavity on left

incisor

Dirty clothesUntidy appearance

Unfixed hair

Yellowish teeth

Self care deficit related to poorpersonal hygiene as evidenced

by foul breath odor, untidy

appearance, oily hair, and

infrequent bathing secondary

to liver cirrhosis.

Short term:After 1 hour of nursing

intervention, the patient should

look tidy and pleasing. He should

have taken a bath, teeth should be

brushed and hair should be fixed.Long Term:

After nursing intervention, the

patient should have maintained a

tidy outlook with a pleasing

personality. Proper hygienetechniques should be maintained

and practiced even after

hospitalization.

I ntervention Rationale Evaluation


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Independent Nursing

intervention:


patient and NPI done.2. Assessed the patients

appearance and hygiene.

3. Rendered Physical

examination

4. Rendered patient health

teaching about proper hygieneand its importance.

5. Advised patient to take regular

baths and to brush teeth for at

least 3x a day.

Collaborated Nursing

intervention

1. Advised the guardian to

always remind and encourage

the patient to take a bath daily

and brush teeth.


- To gather more information

and data to assess hiscondition.

- For base line and additional

data

- To increase patients

knowledge about proper

hygiene and for him to knowthe techniques to keep himself

tidy.

- To keep self tidy and clean,

and to have a good personal

hygiene.

- To maintain patient hygiene

and to remind him to keep hi

Goal Met


patient took a bath and tidied

himself.


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NURISNG CARE PLAN: Disturbed Sleep

PatternAssessment Diagnosis Planning

Subjective Data:

hindi ako nakakatulog ng

maayos dito. Namamahay kasi

ako eh.Objective Data:

Sleep hours before

hospitalization: 78 hours

Sleep hours after

hospitalization: at least 34

hours

Interrupted sleep at night

(+) restlessness

(+) irritability

Disturbed sleep pattern

related to

Unfamiliar sleep

surroundings and lightingas evidenced by

interrupted sleep hours of

at least 3 hours,

restlessness, and

irritability.

Short term:

After 1 hour of nursing


sleep hours should increasefrom 34 hours to at least

8 hours. Signs of irritability

and restlessness should be

lessened.

Long Term:


the patient should have a

regular sleeping pattern and

no signs of restlessness and

irritability.

Interventiona Rationale Evaluation


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Interventiona Rationale Evaluation



patient.2. Rendered physical examination.

3. Interviewed the patient regarding

his sleeping habits and pattern.

4. Provided comfort to the patient.

5. Suggested diversional activities

before sleep such as listening to

classical music or reading a book.

6. Advised patient to use eye cover if

the room is too bright, and to pray

before sleeping.


1. Advised guardian to keep the

surrounding quiet and peaceful.

- To gain trust from the

patient- For base line data

- To gather more

information regarding

the patients concern

- To promote relief to

patient

- To help the patient to

sleep, and to stimulate

eyes in order for the

patient to have

continuous sleep.

- To help the patient to

sleep properly.

Goal Partially Met

After nursing

intervention, thepatient had

decreased signs of

restlessness and

irritability but was

not able to sleep

continuously for 8

hours.


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NURISNG CARE PLAN: Impaired Skin

Integrity

Assessment Diagnosis Planning

Subjective Data:

May sugat ako sa ulo

tsaka marami akong

peklat dahil na rin sapagbibisikleta

Objective Data:

(+) wound @ left parietal

side of the head

(+) dry skin

Poor skin turgor

Thin in appearance

Inadequate food intake

6 glasses of water a day

Impaired skin integrity related

to presence of wound and

imbalanced nutritional state as

evidenced by wound at leftparietal side of the head, dry

skin, poor skin turgor, and

inadequate food intake,

secondary to liver cirrhosis.

Short term:

After nursing


skin should be moist andwound should be cleaned

and disinfected.

Long Term:

After nursing

intervention, the patient

should have maintained

integrity of skin by

keeping it moist and

cleaned daily.



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1. Established rapport with the patient

2. Rendered physical examination

3. Assessed patients wound on thehead

4. Performed wound care to the

patient and provided frequent skin

care

5. Informed and demonstrated the

proper wound dressing to the

patient and guardians

6. Advised patient to avoid use of soap

and alcohol based lotions.

7. Advised patient to take a bath daily.


1. Instructed the guardian to perform

wound care and assess skin of the

patient from time to time.


- For base line data

- To gather more information anddata to assess his condition

- To prevent infection

- To ensure continuity of care

- To keep the skin moist and

hydrated

- To ensure continuity of care and

to prevent further complications.

Goal Met

After nursing

intervention, the

patients skinappeared moist

and the wound

was cleaned.

The patient

understood and

complied with

the health

teaching of the

student nurse.

NURISNG CARE PLAN: Impaired


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NURISNG CARE PLAN: ImpairedDentition


Subjective Data:

Kulang na talaga yung ngipin ko.

Di na ako nagpupustiso kasi

nawala ko. Pero dati may pustiso

ako.

Objective Data:

Incomplete number of teeth: 10

(+) tooth cavity: left lower incisor

(+) foul breath odor

Yellowish teeth

Not frequent tooth brushing: 4

times a week.

Excessive Alcohol intake: 12

cases per session

Impaired dentition

related to ineffective oral

hygiene and dietary

habits as evidenced by

halitosis, teeth

discoloration, dental

carries, and non frequent

tooth brushing.

Short term:

After 1 hour of nursing

intervention the patient should

have no foul breath odor and

should have white teeth.

Long Term:


patient should have continued the

use of dentures and should have a

regular check-up with the dentist.



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patient.

2. Rendered physical examination

3. Assessed the patients dentition,

teeth, and mouth.

4. Advised patient to brush teeth for

at least 3 times daily.

5. Advised patient to continue use of

dentures and to visit a dentist for

every 6 months.


1. Advised patient for referral to a

dentist for complete checkup

and for replacement of dentures.


- For base line and additional data- To gather more information and

data to assess his condition

- To keep teeth healthy and clean.

- To have a proper consultation

about dentition and to prevent

further complications and

cavities.

- For continuity of care and for

further assessment of the patients

condition.

Goal partially Met


the patient does not have

foul breath odor but the

teeth is still yellowish.


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Independent Nursing

intervention:

- Established rapport with the

patient- Rendered physical

examination.

- Maintained patients clear

liquid diet.

- Listened to the patients

verbalization of concerns- Explained the importance of

maintaining the diet prescribed

to the patient.

- Encouraged the patient to

endure diet until his condition

was already stabilized.

Collaborated Nursing

intervention

- Advised guardian not to feed

the patient solid food unless

the doctors diet order was

changed.

- To gain trust from the patient.

- For base line data

- As prescribed by the physician

- To promote comfort and to provide

an outlet for the patient.- To provide knowledge and

additional information that the

patient needs.

- To prevent further complication and

problems to the patient.

Goal Met


the patient understood the

importance of propernutrition and its risks.


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NURISNG CARE PLAN: Risk for

Bleeding


Objective Data:

With history of upper gastro intestinal

bleeding

With history ofHematochezia (blood in stool) prior to

admission

Medications of:

Vitamin K

Tranexamic acid

For blood clottingLaboratory result before blood

transfusion:

Platelet count of 152 (normal 150

450) : near to minimal range

Blood transfusion of Packed RBC on

March 10, 2013

Risk for bleeding related to

scarring of upper gastro

intestinal tract due to liver

cirrhosis.

Short term:

After 1 hour of nursing intervention,

the patient should be free from signs

of bleeding.Long Term:

After nursing intervention, the patient

should not have any reports of

recurrent bleedings.


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PROGRESS NOTESXIV. PROGRESS NOTESPatient: R. R. A.

Diagnosis: Liver Cirrhosis, Acute Anemia secondary to UGIB

On the first day of our duty that is on March 11, 2013 Monday in GEAMH (General

Emilio Aguinaldo Medical Hospital), we handle our client RRA in the medical ward with the

diagnosis of Liver Cirrhosis, Acute Anemia, secondary to (UGIB) upper gastrointestinalbleeding. We received the patient awake in bed in a sitting position with IVF PNSS 1L level

300cc@ Left metacarpal vein regulated @ 31-32gtts/min. He is conversant and ambulatory

upon the interview, but he feels irritable on that time because of hot atmosphere in the

medical ward it makes him uncomfortable feelings. After assessing the patient condition and

NPI is done, we take the initial vitals sign of the patient. There are all-normal in v/s except

his BP it increase in 140/90. We immediately refer to the staff nurse about the increase BP ofour patient. In addition, to alleviate the uncomfortable feelings of our clients, we established

rapport to the patient and provided therapeutic communication. We also encouraged the

patient to verbalize his feelings to relieve his uncomfortable feelings. When the patient felt

relax and rested, we do the physical assessment thoroughly.


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On the second day our duty that is on March 12, 2013

Tuesday, after the endorsement we received our patient awake

on bed in a supine position with an IVF PNSS 1L withincorporated with B-complex at the level of 250cc regulated at

31-32gtts/min, he is conscious and coherent. Again, we take

the initial vital signs of our patient his BP is 130/80, which is

lower than on the first day. We do again nursing patientinteraction. Then, during the interview, he told as that he feels

abandoned, and he missed her parents very much. We advised

him to do some diversional activities such as, talking with the

other patients and listening to music. We also encouraged him

to relax and avoid thinking of stressful things to lessen his

loneliness. After a while, one of his relative visited him in the

medical ward, our patient feel better and happy.


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On the third day of our duty that is onMarch 13, 2013 Wednesday, we continued our

health teaching to our patient. We taught andremind them about the prevention ofcomplications that can be accomplished bytreating his liver cirrhosis secondary to upper

gastrointestinal bleeding through taken themedication prescribed by his doctor. We alsoadvised to stop smoking, do exercise as needed

or resuming activities of daily living that can stillbe done by the patient, and the reduction in saltand alcohol intake.


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MEDICATION The patient advised to follow and take the

prescribed medication regimen needed to the

prompt recovery and effective treatment.

Teachings and giving information about

medicines adverse effects and its side effects

are also put into practiced. The following

medications were prescribed as follows:

Lanexamic acid

Rebamibide

Furosemide

Omeprazole

Morlam forte

Vit.K


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ENVIRONMENT/ EXERCISE Advised the patient to have a safety environment

and avoid hazardous places to keep away from

further injury or accident. Instructed the patient to

do exercises and relaxation technique as

tolerated such as walking, yoga and meditation.

The patient will have no restrictions to physical

activities; however, the patient should pay

attention to their body in reaction to certainactivities. Gradually increase activities at a

comfortable and individual pace.

TREATMENT Instructed the patient to comply the long-term

treatment for his condition and to monitor the

possible sign and symptoms of the disease.

HYGIENE Instructed the patient to do proper hygiene such as,

take a bath every day, trimming the nails, changing

clothes everyday and brushing his teeth after eating.


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OPD The patient instructed to have his follow-up check-up with a

hepatologist or gastroenterologist in the OPD for his quick

recovery.

DIET Encouraged patient to avoid fatty/oily foods; avoid sour

food and drinks.

Avoid spicy foods otherwise nothing by mouth if with

persistent abdominal pain.

Encouraged patient to increase fluid intake.

Encouraged patient to eat foods rich in vitamins and

nutritious foods.

Recommending dietary changes of decreased/avoiding fat

intake is prudent; this may decrease the incidence of

gastrointestinal bleeding.

Since maximum liver function is essential for proper bile

formation, it is also important to reduce chemical stress

upon the liver (remember, the liver produces the bile

which must have proper levels of cholesterol, bile acids

and lecithin and synthetic chemicals are well known for

weakening liver function).


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SPIRITUAL CARE Advised the patient to read spiritual and uplifting books. Think about what

you read, and find out how you can use the information in your life

Meditate for at least 15 minutes every day.

Learn to make your mind quiet through concentration exercises and

meditation.

Acknowledge the fact that you are a spirit with a physical body, not a

physical body with a spirit. If you can really accept this idea, it will change

your attitude towards many things in your life.

Look often into yourself and into your mind, and try to find out what is it that

makes you feel conscious and alive.

Advised the patient to think positive. If you find yourself thinking negatively,

immediately switch to thinking positively. Be in control of what enters your

mind. Open the door for the positive and close it for the negative.

Develop the happiness habit, by always looking at the bright side of life and

endeavoring to be happy. Happiness comes from within. Do not let your

outer circumstances decide your happiness for you.

Exercise often your will power and decision making ability. This strengthens

you and gives you control over your mind.


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3rd Year 2nd Sem Part 2 [Autosaved]

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