Question

Nursing Diagnoses, Goals and Outcomes,
Interventions, Evaluation:    of liver cirrhosis patient

Answer 1

CIRRHOSIS OF LIVER

It is a condition in which the liver does not function properly due to long term damage. This damage is characterised by the replacement of normal liver tissue by scar tissue. Typically , the disease develops slowly over months or years.

PREDISPOSING FACTORS

-malnutrition

- effects of alcohol abuse

- chronic impairment of bile excretion( biliary obstruction in the liver and common bile duct )

- necrosis from hepatotoxins or viral hepatitis

- congestive heart failure

CLINICAL MANIFESTATIONS

EARLY

-anorexia, nausea, indigestion,

-aching or heaviness in right upper quadrant

-weakness and fatigue

LATE SIGNS

- intermittent jaundice, pruritis,edema,ascites, prominent abdominal wall veins , ecchymosis, bleeding tendencies, anemia,infection, gynecomastia, testicular atrophy, neurological changes

1.NURSING DIAGNOSIS :

Impaired breathing pattern related to decreased lung expansion secondary to intraabdominal fluid collection as manifested by dyspnea

Goal

the patient breathing status will be maintained to normal

Interventions

- monitor vital signs to know baseline data

- monitor respiratory rate, rhythm and depth to identify dyspnea id dueto fluid accumulationin th eabdomen

- auscultate breath sounda, noting craclkles, wheezesand ronchi -it indicates developing complications and increasingrisk of infection

- investigate changes inLOC- to idenify changes in mentation may refect hypoxemia

- keep head of bed elevated ,.positoin on sides

- encourage frequent repositioning and deep breathing exercises -aids in lung expansion and mobilising secretions

-provide supplemnetal oxygen if needed -it helps to prevet hypoxia

Evaluation

the breathing pattern is returned to normal

2. NURSING DIAGNOSIS

f luid volume excess related to compromised regulatory mechanism to cirrhosis of the liver as manifested by pallor, abdominal distention

Goal

- the fluid status of the patient will be improved

Interventions

- monitor the vital signs of client to know baseline data of client

- measure intake and output chart to know fluid status

- monitor  blood presssure

-assess repiratory status to identify there pulmonary congestion

-monitor abdominalgirth to identify accumulation of fluid

-provide occasionalice chips if NPO

- restrict sodium and fluid as ordered

Evaluation

After 6 hours of nursing interventions , the patient demonstrated stabilised fluid volume and decreased edema and abdominal girth  

3.NURSING DIAGNOSIS

Imbalance nutrition lesss than body requirement related to loss of appetite secondary to ascites as evidenced by refusalto eat,weak in appearance

Goal

the nutrition status of patient will be improved

Interventions

-Monitor vitalsigns to know baseline data

-assist in oral hygiene before meals because a clean mouth enhances appetite

-disuss eating habits including food preferences that helps to identify likes and dislikes of food of patient

- serve favorite foods that are not contraindicated

-prevent or minimise unplesant odors during mealyime

- serve foods that are attractive and palatable -

- recommend small, frequent meals

-restrict intake of caffeine,gas producing or spicy and excessively hot or cold foods that aids in reducing gastric irritation

Evaluation

the nutrition status of the patient is improved

.