final ncp hannah.docx

8/18/2019 final ncp hannah.docx

1/23

1

CUES NURSING

DIAGNOSIS

RATIONALE GOALS AND

OBJECTIVES

INTERVENTION RATIONALE EVALUATION

Subjective:

Objective:

Decreased

hemoglobin,

Pale lips and

conjunctiva,

(+)anemic

Decreased tissue

perfusion related to

decreased

hemoglobin

concentration in the

blood from anemia

Decrease in o!"gen

resulting in the

failure to nourish

the tissues at the

capillar" level

(#issue perfusion

problems can e!ist

$ithout decreasecardiac output%

ho$ever, there ma"

be a relationship

bet$een cardiac

output and tissue

perfusion)

#ransport of o!"gen

is impaired $ith

anemia

&emoglobin is

lac'ing or thenumber of *s is

too lo$ to carr"

adeuate o!"gen to

the tissues and

h"po!ia develops

#he bod" attempts

to compensate for

tissue h"po!ia b"

increasing the rate

of * production,

increasing cardiac

output b"

increasing stro'e

volume heart rate,

redistributing blood

from tissues $ith

high o!"gen needs

S&O# #-.:

/fter 0 hours of

nursing

intervention:

a) ill be able to

prevent the

occurrence ofh"povolemic

shoc'

b) Prevent the

occurrence of

h"po!ia

2O34 #-.:

/fter 5 months ofcollaborative

intervention, the

patient $ill be able

to:

a) .aintain

hemoglobin level in

normal range

INDEPENDENT:

67nvestigate

changes in level of

consciousness,

reports of di88iness

or headache

6lood transfusion

as ordered

67nvestigate

reports of chest

pain 3ote location,ualit", duration,

and $hat relieves

pain

6/uscultate apical

pulse .onitor

cardiac rate or

rh"thm if

continuous -*4 is

available

indicated

6*hanges ma"

re9ect inadeuate

cerebral perfusion

as a result of

reduced arterial

blood pressure

Note: change insensorium may also

refect elevated

ammonia levels or

hepatic

encephalopathy in

clients with liver

disease.

6#o correct anemia

6.a" re9ectcardiac ischemia

related to

decreased

perfusion 3ote:

7mpaired

o!"genation status

resulting from blood

loss can bring on .7

in clients $ith

cardiac disease

6D"srh"thmias and

ischemic changes

can occur as a

result of

h"potension,

h"po!ia, acidosis,


2/23

5

(.edical Surgical

3ursing 0th edition

b" lac' and

&a$'s, p 5;;


3/23

?

pallor, redness

.assage gentl"

$ith lotion *hange

position freuentl"

6-ncourage patient

to eat foods rich in

iron, such as:a. Malunggay

b. Alugbati

c. Dilis

d Ganas

DEPENDENT:

6Provide

supplemental

o!"gen if indicated

6/dminister 7@

9uids as indicated

6#ransfuse blood as

ordered (S*)

6/dminister

Aerrous Sulfate

(AeSOB)

COLLABORATIVE:

6epeat ** post

#

to vasoconstrictive

therap", bleeding

into biliar" tract, or

perforation or onset

of peritonitis

6*ompromised

peripheral

circulation

increases ris' ofs'in brea'do$n

6#o aid in

maintenance of

normal hemoglobin

level

6#reats h"po!emia

and lactic acidosis

during bleeding

6.aintains

circulating volume

and perfusion

67n order to regain

the normal

hemoglobin level

6#o prevent

e!cessive 9uid

volume in the bod"

6#o treat and


4/23

B

CUES NURSING

DIAGNOSIS

RATIONALE

GOALS AND

OBJECTIVES

INTERVENTION

prevent 7ron

De=cienc" /nemia

6#o monitor if there

is an improvement

in the &emoglobin

level in the bod"

RATIONALE

EVALUATION

Subjective:

Objective:

is' for 7nfection

related to poor

$ound healing

S&O# #-.:

/fter 0 hours of

nursing

intervention, the


to:

a 7dentif"

behaviors toprevent or reduce

ris' of infection

2O34 #-.:

INDEPENDENT:

6Perform or

promote meticulous

hand$ashing b"

caregivers and

client

6.aintain strict

aseptic techniue$ith procedures or

$ound care

6-ncourage

freuent position

6#o prevent cross

contamination or

bacterial

coloni8ation

6educe ris' of

bacterial

coloni8ation orinfection

6#o promote


5/23

<

/fter 5 months of

collaborative

intervention, the

patient $ill be free

from an" ris' of

infection

change or

ambulation,

coughing and

D*-

6.onitor

temperature 3ote

presence of chills,

tach"cardia, $ith

or $ithout fever

Collaborative:

6Obtain specimens

for culture and

sensitivit" as

indicated

6/dminister topical

antiseptic%s"stemic

antibiotics

ventilation of the

lung segments

6e9ective of

in9ammator"

process or infection,

reuiring evaluation

and treatment

6@eri=es presence

of infection,

identi=es speci=c

pathogens, and

in9uence choice of

treatment

6.a" be used

proph"lacticall" to

reduce coloni8ationto treat speci=c

infectious process

CUES NURSING

DIAGNOSIS

RATIONALE GOALS AND

OBJECTIVES


Subjective: /n!iet" related to

recurrence of

melena

/ vague, uneas"

feeling or feeling of

fear to$ardssomething that is

not familiar or is not

ne$ to the patient

S&O# #-.:

/fter 0 hours ofnursing

intervention, the


to :

INDEPENDENT:

6-ncourage

verbali8ation ofconcerns /ssis

client in e!pressing

feelings b" activel"

listening

6-stablish a

therapeuticrelationship, assist

client in dealing

$ith healings, and

provides

opportunit" to


6/23

C

Objective:

a nderstand his

conditions and the

treatment available

that can help him

b /ppear rela! and

report an!iet" is

reduced to a

manageable level

2O34 #-.:

/fter 1 month of

collaborative

intervention, the


to:

a e $orr"free

about his condition

6/c'no$ledge that

this fearful situation

and that other have

e!press similar

fears

6Provide accurate,concrete

information about

$hat is being done

6Provide a calm

restful environment

DEPENDENT:

6/dministermedications as

indicated

clarif"

misconception

6hen the client is

e!periencing o$n

fear, the validation

that this feelings

are normal, can

help client to feel

less isolated

67nvolves client in

plan of care and

decreases

unnecessar"

an!iet" about

un'no$n

6emoving client of

outside stressors,

promotes

rela!ations andma" enhance

coping s'ills

6Sedatives or anti

an!iet" agents ma"

be used on

occasion to reduce

an!iet" and

promote rest


7/23

E

CUES NURSING

DIAGNOSIS

RATIONALE GOALS AND

OBJECTIVES


Subjective:

Objective:

7mbalance nutrition:

2ess than bod"

reuirements

related to

inadeuate diet

2iver cirrhosis

particularl" a>ects

protein metabolism

$ith reduction in

s"nthesis of

transport proteins

such as albumin

#his is caused b" acombination of

decreased

functional liver

mass and

alterations in amino

acid demands

educed gl"cogen

storage also

increases amino

acid needs for

gluconeogenesis

$hile ongoingin9ammation alters

the pattern of

amino acid

reuirements,

precipitating

speci=c amino acid

shortages #his

problem is then

made $orse b" a

reduced capacit"

for transamination

reaction, $hich $illallo$ the liver to

generate amino

acids in shorts

suppl" form those

available /s a

S&O# #-.:

/fter 0 hours of

nursing

intervention, the


to:

a @erbali8e theimportance of good

nutrition

b Aormulated diet

modi=cations of his

choice

2O34 #-.:

/fter 5 months of

collaborativeinterventions, the


to:

a Demonstrate

progressive $eight

gain

b -!perience no

further signs of

malnutrition

c eceive adeuate

nutrition as

evidenced b" no

$eight loss and no

manifestations of

INDEPENDENT:

6.odif" the diet

6Place the client on

dail" $eight, input

and output

monitoring, and

calorie counts

6-valuate client

ris' formalnutrition

6Determine

interest in eating

and abilit" to che$,

6Diet should

provide ample

protein to rebuild

tissue but not

enogh protein to

precipitate hepatic

encephalopath"(E< gda"),

suFcient

carboh"drates to

maintain $eight

and to spare protein

stores

6#o assess 9uid

and nutritional

balance

60


8/23

0

conseuence of all

the above, patients

$ith cirrhosis need

considerabl" high

minimum dail"

protein inta'e of

around C; gms or

(15 gms'gda") to

maintain nitrogen

balance rather than?< gms or


9/23

G

acute liver disease

or decompensated

chronic liver

disease 2evels of

overall energ"

demands in

cirrhotic liver

disease are subject

to debate $ith

resting energ"e!penditure or --

studies sho$ing

con9icting results

#he largest stud" to

date in BE? patients

sho$ed that ?BH of

cirrhotics $ere

h"permetabolic or

indirect

caloriemetr" but

the causes of

elevated -- $ereunclear and

unrelated to clinical

or biochemical

assessment of

impaired liver

function #he

increased energ"

e!penditure ma"

therefore re9ect

intrahepatic events

in some liver

disease such as thes"stemic

in9ammator"

response Overt or

hidden infection

also increases --

allo$ed% avoid

those containing

ammonium

6Provide vitamin

supplements as

indicated

6estrict inta'e of

ca>eine, gas

producing or spic"

and e!cessivel" hotor cold foods

6-ncourageprovid

e freuent

mouthcare

especiall" before

meals

6Provide assistance$ith activities as

needed Promote

undisturbed rest

periods especiall"

before meals

demonstrate loss of

interests in foods

because of nausea,

fatigue, general

$ea'ness and

malaise

6Salt limitations

can help manage

9uid complicationsin cirrhosis Salts

substitutes

enhances the 9avor

of food and aid in

increasing appetite%

ammonia

penetrates ris' of

encephalopath"

6@itamins /,D,-,

and ' are suppliedif fat absorption is

adeuate

Areuentl" vit I

injections are

ordered to improve

blood clotting

factors

6/ids in reducing

gas or strict

irritation or diarrhea

and abdominaldiscomfort that ma"

impair oral inta'e or

digestion

6*lient is prone to

1;


10/23

1;

in cirrhotics and the

presence of ascites

per se seems to

contribute since

falls in -- are seen

$ith paracentesis

3evertheless, in

one stud"

h"permetabolism

$as still present insome patients 1

"ear after insertion

of transjugular

intrahepatic

Portos"stemic

shunts, even

though ascites had

resolved

DEPENDENT:

6/dminister

medications as

indicated:

a @itamin

supplements and

vitaminsb Digestive

en8"mes

c /ntiemetics

6.aintain in 3PO

$hen indicated

COLLABORATIVE:

6.onitor nutritional

lab studies

6*onsult $ith

sore and or

bleeding gums

$hich contributes

to anore!ia

6*onserving

energ" reduces

metabolic demands

of the liver and

promotes cellularregeneration

6*lient ma" be

vitamin de=cient

because of previous

poor dietar" habits

/lso the injured

liver is unable to

utili8e vitamins and

anemia (due to ironand folic acid

de=cienc") ma"

e!ist

647 rest ma" be

reuired in acutel"

ill clients to reduce

demands of the

liver and production

of ammonia or urea

in the 47 tract

hen this is thecase, nutrition must

be applied $ith

another method

11


11/23

11

dietician to provide

diet that high in

calories and simple

carboh"drates

64lucose ma"

decreased because

of impaired

g"cogenesis

depleted gl"cogen

stores or

inadeuate inta'e

Protein ma" be lo$

because of impaired

metabolism,decreased hepatic

s"nthesis or loss

into peritoneal

cavit"

6&igh calorie foods

are desired in as

much as client

inta'e is usuall"

limited

CUES NURSING

DIAGNOSIS

RATIONALE GOALS AND

OBJECTIVES

INTERVENTIONS RATIONALE EVALUATION

Subjective: De=cient 9uid

volume related to

ruptured

esophageal varices

-sophageal varices

are a comple! of

longitudinal

tortuous veins at

S&O# #-.:

/fter 0 hours of

nursing

73D-P-3D-3#:

6.onitor client

inta'e% teach the

client to avoid

6large amounts of

sugars, alcohol, and

ca>eine act as

15


12/23

15

Objective:

(+)hematemesis(+)47 related to

-@

the lo$er end of the

esophagus,

enlarged and

s$ollen as the

result of portal

h"pertension

interventions, the


to:

a

b

co>ee, tea,

grapefruit juice,

sugared drin's, and

alcohol

6.onitor output%

ensure at least

ectivel", $eights

should be measured

at the same time on

the same scale $ith

the same clothes

6#hese laborator"

studies $ill re9ect

h"dration status

67f hemorrhage

from ruptured

varices occurs,

monitor P, P, ,

and urine output

continuousl" /ssist

$ith interventions

to restore

6#o reduce ris's of

deh"dration

1?


13/23

1?

before fasting

6evie$ the

clientJs

medications

6.onitor for signs

of deh"dration,

di88iness, and

$ea'ness% mucous

membrane% and

inta'e versus

output

6-!plain to the

client the need to

drin' 9uids and to

use a s"stem for

reminding

himselfherself not

to rel" on thirst

6*ertain

medications can

contribute to

deh"dration

6Output ma"

e!ceed inta'e,

$hich ma" alread"be inadeuate to

compensate for

insensible losses

6#he elderl" are at

high ris' for

deh"dration due to

decreased thirst

sensation,

decreased 9uid

volume, and

decreased abilit" toconcentrate urine

(ennett, 5;;;)

6Strategies that

include verbal

prompting and

choices of 9uids $ill

increase 9uid

inta'e -lderl"

clients $ho live

alone need help to

design prompts that$ill remind them to

drin'

1B


14/23

CUES NURSING

DIAGNOSIS

RATIONALE GOALS AND

OBJECTIVES


Subjective:

Objective:

(+) bod"

$ea'nessfatigue

/ctivit" 7ntolerance

related to bod"

$ea'ness

secondar" to

muscle $asting

S&O# #-.:

/fter 0 hours of

nursing

interventions, the


to%

a

b

73D-P-3D-3#:

6#a'e vital signs

eg, resting pulse,

blood pressure, and

respirations

6-ncourage

bedrest to chair rest

initiall" 2imit

activit" on basis of

pain or adverse

cardiac response

Provide nonstress

diversional

activities

6Plan rest periodsaccording to the

clientJs dail"

schedule

6#o serve as

clientJs baseline

data esponse to

activit" can be

evaluated b"

comparing

preactivit" blood

pressure, pulse, and

respiration $ith

postactivit" results

#hese, in turn, arecompared $ith

recover" time

6educes $or'load

and energ"

consumption

6est relieves the

s"mptoms of

activit" intolerance

#he dail" schedule

is planned to allo$

1


15/23

67dentif" factors

that undermine the

clientJs con=dence

6&elp the client to

identif" progress

Do not

underestimate the

value of praise and

encouragement as

e>ective

motivational

techniues

for alternating

periods of activit"

and rest and is

coordinated to

reduce e!cess

energ" e!penditure

6#o promote

participation in

activities to achievea level of activit"

desired b" the

client for the

therapeutic

regimen

6Strategies that

are individuali8ed

can increase

motivation

1C


16/23

CUES NURSING

DIAGNOSIS

RATIONALE GOALS AD

OBJECTIVES


Subjective:

K Iada nasu'a a'o

hin ma" dugo,

nauro li$at a'o hin

maitomL as

verbali8ed b" thepatient

Objective:

(+)47

(+).elena

(+)&ematemesis

Decreased

hemoglobinDecreased *s

Decreased

hematocrit

7ne>ective tissue


bleeding

tendencies

S&O# #-.:

/fter 0 hours of

appropriate nursing

intervention given

to patient, he $illbe able to:

a

b

Independent:

67nvestigate

sudden changes or

continued

alterations in

mentation, such asan!iet", confusion,

letharg", and

stupor

67nspect for pallor,

c"anosis, mottling,

and cool or clamm"

s'in

3ote strength of

peripheral pulses

6*erebral perfusion

is directl" related to

cardiac output and

is

in9uenced b"electrol"te and

acidbase

variations, h"po!ia,

and s"stemic

emboli

6S"stemic

vasoconstriction

resulting from

diminished cardiac

output ma" be

evidenced b"decreased s'in

perfusion and

diminished pulses

(efer to 3D: ris'

1E


17/23

6.onitor

respirations, noting

$or' of breathing

6.onitor inta'e,

noting changes in

urine output

ecord urine

speci=c gravit", as

indicated

6.onitor for

hemorrhage

6/ssess

gastrointestinal

function, notinganore!ia, decreased

or

absent bo$el

sounds, nausea and

vomiting,

for decreased

*ardiac

Output)

6*ardiac pump

failure and ischemic

pain ma"

precipitate

respirator"

distress% ho$ever,sudden or

continued d"spnea

ma" indicate

thromboembolic

pulmonar"

complications

6Decreased inta'e

or persistent

nausea ma" result

in reduced

circulating volume,$hich negativel"

a>ects perfusion

and

organ function

Speci=c gravit"

measurements

re9ect

h"dration status

and renal function

6.onitor client for

bleeding gums,purpura, melena,

hematuria, and

hematemesis

6educed blood

10


18/23

abdominal

distention, and

constipation

6-ncourage active

or assist $ith

passive lege!ercises, $ith

avoidance of

isometric e!ercises

6/ssess for pain in

lo$er e!tremit" and&omansJ sign,

er"thema, and

edema

67nstruct client in

application and

periodic removal of

antiembolic hose

$hen used

Collaborative:

6/ppl" elasticcompression

stoc'ings or

intermittent

pneumatic

compression

9o$ to mesenter"

can produce

gastrointestinal

d"sfunction, such

as loss of

peristalsis

Problems ma" be

potentiated or

aggravated b" use

of analgesics,decreased

activit", and dietar"

changes

6-nhances venous

return, reduces

venous stasis, and

decreases

ris' of

thrombophlebitis%

ho$ever, isometric

e!ercises canadversel" a>ect

cardiac output b"

increasing

m"ocardial

$or' and o!"gen

consumption

67ndicators of deep

vein thrombosis

(D@#), although calf

pain is

not al$a"s present

62imits venous

stasis, improves

venous return, and

reduces ris' of

1G


19/23

devices, as

indicated

thrombophlebitis in

client $ho is limited

in activit"

6.a" be desired to

prevent D@#,

especiall" in client

$ho is

unable to be out of

bed or cannotambulate freel"

CUES NURSING RATIONALE GOALS AND INTERVENTIONS RATIONALE EVALUATIO

5;


20/23

DIAGNOSIS OBJECTIVESSubjective:

Objective:

7ne>ective tissue


h"povolemia

S&O# #-.:

/fter 0 hours of

appropriate nursing

interventions, the


to:

a

b

7ndependent:

6.onitor changes

in the level of

consciousness,

complaints of

di88iness or

headaches

6/uscultate theapical pulse 4uards

heart rate and

rh"thm $hen there

is continuous -*4

6/sses the s'in to

cold, Pale, s$eating,

slo$ capillar" =lling

and peripheral pulse

is $ea'

63ote reports of

abdominal pain,

especiall" sudden

severe pain, or pain

spreading to the

shoulders

6*hange ma"

indicate inadeuate

cerebral perfusion

due to arterial blood

pressure

6*hange

d"srh"thmias andischemia can occur

as a result of

h"potension,

6@asoconstriction is

a s"mpathetic

response to the

decline in

circulation volume

and or ma" occur

as a side e>ect of

vasopressin

6Pain caused b"

gastric ulcer often

disappears after

hemorrhage due to

#he bu>er e>ects of

blood

51


21/23

*-S 3S734D7/43OS7S

/#7O3/2- 4O/2S /3DOM-*#7@-S

73#-@-3#7O3S /#7O3/2- -@/2/#7O

Subjective:

Objective:

/ctivit" 7ntolerance

related to anemia

from poor nutrition

and bleeding

S&O# #-.:

/fter 0 hours of

appropriate nursing

intervention, the


to:

a

b

2O34 #-.:

73D-P-3D-3#:

6/lternate rest and

activit"

6/ssist $ith

activities of dail"

living

6.onitorhemoglobin and

hematocrit levels

/ssist $ith the

treatment of 47

bleeding

6/dminister blood

transfusions or iron

supplements as

ordered to treat

anemia

6#his conserves

energ" and reduces

demands on liver

67ncreases activit"

tolerance and

endurance

6/llo$s detection

and treatment ofgastrointestinal

bleeding

6lood transfusions

$ill immediatel"

improve hemoglobin

and hematocrit

levels, $hereas iron

replacement

therap" $ill ta'e

longer to bee>ective

6Decreased

production of

clotting factors can

#he client $ill

able to tolerate

activit" better,

perform more /

55


22/23

lead to hemorrhage

and anemia

*-S 3S734

D7/43OS7S

/#7O3/2- 4O/2S /3D

OM-*#7@-S

73#-@-3#7O3 /#7O3/2- -@/2/#7O

Subjective:

Objective:

(+) stomach

guarding

*hronic pain relatedto ph"sical

response

Pain occurs fromulceration and

aeration of mucosa

of the upper

gastrointestinal

organs including the

stomach and

esophagus $hich

indicated presence

of melena,

hematemesis, or

blood in gastric

contents(3ursing *are Plan

4uidelines for

7ndividuali8ing

*lient *are /cross

the 2ife Span, 0th

edition)

/fter 0 hours ofnursing

intervention,

patient%

a verbali8es relief

from pain

b demonstrates

rela!ed bod"

posture and able to

sleeprest

appropriatel"

7ndependent%

63ote reports of

pain including its

location, duration,

and intensit" from a

pain scale of ;1;

6evie$ factors

that

aggraviatealleviate

pain

63ote nonverbal

pain cues such as:

abdominal

guarding,

reluctance to move,

restlessness,

tach"cardia,

diaphoresis,etc

6Pain is not al$a"s

present Presence of

such should be

compared $ith the

clientJs previous

pain s"mptoms

#his comparison

ma" assist in the

diagnosis of etiolog"

of bleeding and

development ofcomplications

6&elpful in

establishing

diagnosis and

treatment needs

63onverbal cues

ma" be both

ph"siological, and

ma" be used in

conjunction $ith

verbal cues to

evaluate e!tent and

severit" of the

problem

5?


23/23

6Provide small,

freuent meals as

indicated

67dentif" and limit

foods creating

discomfort

6/ssist $ith active

and passive O.

e!ercises

Dependent:

6/dminister

medications as

indicated:

/nalgesics/cetaminophen

/ntacids

/nticholinergen

*ollaborative:

6Provide and

implement dietar"

modi=cations

6Aood has an acid

neutrali8ing e>ects

and dilutes the

gastric content

6Speci=c foods that

cause distress

varies among

certain individuals

6educe joint

sti>ness, minimi8ing

pain and discomfort

6#o help relieve

acutesevere pain

#o promote general

comfort and rest #o

decrease gastric

acidit" b"

absorption or b"chemical

neutrali8ation

6hen oral inta'e

is allo$ed, food

choices depends on

the diagnosis and

its etiologic factors

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