Assessment Nursing Scientific Planning Intervention Rationale Evaluation

Diagnosis Rationale

Subjective: Ineffective Ascites is the INDEPENDENT:

“Danay nakukurian ako breathing pattern abnormal After one hour 1. Monitor respiratory rate, 1. Rapid, shallow respirations, or Goal Unmet:
hit akon paghihinga.”, related to ascites accumulation of of nursing depth, and effort. dyspnea may be present because of Client still had
patient verbalized. with decreased fluid in the interventions, hypoxia of fluid accumulation in the dyspnea, and
lung expansion as abdominal cavity. the client will abdomen. arterial blood
“Baga ako hin evidenced by This fluid demonstrate gases showed
nalulumos tungod hit reports of dyspnea, accumulation effective 2. Auscultate breath sounds, 2. Presence of adventitious sounds decreasing O2
tubig ha akon tiyan.”, increased compresses the respiratory noting crackles, wheezes, and reflect accumulation of fluid while level.
patient verbalized. respiratory rate, diaphragm thus pattern and be rhonchi. diminished sound suggests
and low levels of inhibiting the free of atelectasis.
hemoglobin. lungs from dyspnea, with
Objective: maximal arterial blood 3. Investigate changes in level 3. Changes in mentation may reflect
RR of 25 cpm expansion. gases within of consciousness. hypoxemia and respiratory failure.
client’s
Hemoglobin level of acceptable 4. Keep head of bed elevated. 4. Facilitates breathing by reducing
114 g/L (normal value is range. Position client on side. pressure on the diaphragm and
at 140-180 g/L) Source: Medical- minimizes risk of aspirating
Surgical Nursing, secretions.
Abdominal girth of 112 12th Edition by
centimeters. Brunner and 5. Conserve patient’s strength 5. Reduces metabolic and oxygen
Suddarth by providing rest periods and requirements.
ABG Result: assisting with activities.
PO2: 76.2 mmHg
(normal value: 80 - 105 6. Encourage frequent 6. Aids in maximal lung expansion.
mmHg) repositioning and deep-
breathing exercises.

7. Monitor temperature. Note 7. Indicative of onset of infection.

presence of chills. Severely ill client is immuno-
compromised and may not be able to
mount a febrile response.
COLLABORATIVE:
8. Monitor ABGs and pulse 8. Reveals changes in respiratory
oximetry. status and developing pulmonary
conditions.
 9. Provide supplemental 9. May be necessary to treat or
oxygen (2 L/m), as ordered by prevent hypoxia.
the physician.

10. Prepare for/assist with 10. Occasionally may be done to

acute care procedures, such as remove ascites fluid to relieve
paracentesis. abdominal pressure.
a. Explain procedure and its a. Helps obtain patient’s cooperation
purpose to patient. with procedures.

b. Have patient void before b. Prevents inadvertent bladder

paracentesis. injury.

c. Support and maintain c. Prevents inadvertent organ or

position during procedure. tissue injury.

d. Record both the amount d. Provides record of fluid removed

and the character of fluid and indication of severity of
aspirated. limitation of lung expansion by
fluid.

e. Observe for evidence of e. Indicates irritation of the pleural

coughing, increasing dyspnea, space and evidence of pneumothorax
or pulse rate. or hemothorax.

Source: Nursing Care Plans:

Guidelines for Individualizing Client
Care Across the Lifespan, 9th
Edition.
 Assessment Nursing Scientific Planning Intervention Rationale Evaluation
Diagnosis Rationale

Subjective: Excess fluid One function of INDEPENDENT:

“Napansin ko nga baga volume related to the liver is to After 15 1. Assess for presence of 1. Client with cirrhosis may have been Goal Met:
sige iton pagdinako hit decreased levels of synthesize minutes of conditions that can interfere sick for quite a while and have no Client
akon tiyan.”, patient plasma proteins as albumin, a protein nursing with food intake. appetite; presence of nausea and/or verbalized
verbalized. evidenced by maintaining the interventions, vomiting; or abdominal ascites which understanding
edema on the colloidal osmotic the client will causes early satiety. of dietary and
“Nanhuhubag na extremities, pressure in the verbalize fluid
guihapon iton akon mga increasing vascular and understanding 2. Discuss usual eating 2. Factors that affect ingestion and restrictions.
kamot ngan mga tiil.”, abdominal girth, extravascular of dietary and habits, including food digestion of nutrients.
patient verbalized. and serum spaces. With fluid preferences, intolerances, or
laboratory tests hepatic disorders, restrictions. aversions.
indicating the levels of
Objective: hypoalbuminemia. albumin is 3. Evaluate total daily food 3. Provides information about intake,
Decreased levels of decreased causing intake, using food diary if needs, and deficiencies. Client with
albumin at 23 g/L fluids to shift into needed. cirrhosis requires a balanced protein
(normal is at 32-50 g/L) the interstitial diet.
spaces.
Abdominal girth of 112 After an hour 4. Monitor client’s vital 4. Tachycardia and hypertension are Goal Met:
centimeters. of nursing signs. common manifestations of Client
Source: Medical- interventions, hypervolemia. demonstrated
Body weight of 84 kg Surgical Nursing, the client will behaviors to
from 80 kg the day 12th Edition by demonstrate 5. Assess the presence and 5. Edema is the result of fluids shifting monitor his
before. Brunner and behaviors to location of edema from one body compartment to another. fluid status.
Suddarth. monitor his formation.
Edema on extremities fluid status
observed. with vital signs 6. Maintain accurate I&O. 6. Decreased renal perfusion and fluid
within normal Note decreased urinary shifts may decrease the urinary output.
range. output.

7. Monitor infusion rate of 7. Prolonged excessive administration

parenteral fluid closely. potentiates volume overload.

8. Maintain semi-Fowler’s 8. Gravity improves lung expansion by

position. lowering diaphragm and shifting fluid
to the lower abdominal cavity.
 9. Encourage rest periods. 9. Rest, particularly lying down, favors
diuresis and reduction of edema.

COLLABORATIVE:
10. Monitor laboratory 10. Fluid shifts affects sodium levels;
studies, such as sodium, BUN may be increased with renal
potassium, BUN, and dysfunction; ABGs may reflect
ABGs, as indicated. metabolic acidosis.

11. Restrict oral fluids 11. Fluid restriction decreases

(1L/day), as ordered by the extracellular fluid retention.
physician.

12. Provide balanced 12. This can enhance colloidal osmotic

protein (add 2 eggwhites per gradients and promote return of fluid to
meal; 25% albumin infusion the vascular spaces.
for 1 hour OD), as ordered
by the physician.

13. Weigh daily as ordered.

13-14. Evaluates fluid retention.
14. Monitor abdominal girth
as ordered.

15. Administer diuretics as 15. Inhibits reabsorption of sodium and

ordered: Furosemide 40mg water in the ascending limb of the loop
IV OD of Henle increasing loss of potassium
and hydrogen ions.

Spironolactone 100mg 1 tab Completely blocks the effects of

BID aldosterone in the renal tubule, causing
loss of sodium and water, and retention
of potassium.

16. Replace potassium 16. Potassium deficit may occur,

losses, as indicated. (K especially if client is receiving
Chlor 1 tab TID x 6 doses) potassium-wasting diuretic.

Source: Nursing Care Plans: Guidelines

 for Individualizing Client Care Across
the Lifespan, 9th Edition.

Assessment Nursing Scientific Planning Intervention Rationale Evaluation

 Diagnosis Rationale

Subjective: Risk for bleeding The liver plays an INDEPENDENT:

“Nasiring man adto an related to impaired important role in After 30 1. Assess for signs and 1. The GI tract is the most usual Goal Met: Client
doktor na hamubo kuno liver function as the metabolism of minutes of symptoms of bleeding. source of bleeding because of its able to verbalize
iton iya sinisiring nga evidenced by low proteins. It nursing Observe color of secretions mucosal fragility and alterations in understanding of
platelet.”, patient’s wife platelet count and synthesizes almost interventions, and stool. homeostasis associated with current condition
verbalized. prolonged all of the plasma the client will cirrhosis. and demonstrated
prothrombin time. proteins including verbalize behaviors to
“Guinpapag-hirot blood clotting understanding 2. Monitor pulse and BP. 2. An increased pulse with reduce risk of
guihapon iton hiya nga factors such as of current decreased BP may indicate loss of bleeding.
diri masamad.”, prothrombin. condition and circulating blood volume.
patient’s wife demonstrate
verbalized. behaviors to 3. Note changes in mentation 3. Changes may indicate decreased
reduce risk of and level of consciousness. cerebral perfusion secondary to
Source: Medical- bleeding. hypovolemia.
Objective: Surgical Nursing,
Platelet count of 12th Edition by 4. Encourage use of soft 4. In the presence of clotting factor
100x1010 g/L (normal Brunner and toothbrush and avoiding disturbances, minimal trauma can
level is at 150-450x1010 Suddarth. straining for stool. cause mucosal bleeding.
g/L)
5. Apply pressure to small 5. Reducing risk of bleeding and
Prothrombin time of bleeding or venipunctured hematoma.
24.6 seconds (normal sites for longer than usual.
value is at 11-13
seconds) 6. Recommend avoidance of 6. Prolongs coagulation,
aspirin-containing products. potentiating risk for hemorrhage.

COLLABORATIVE:
7. Monitor hemoglobin, 7. Indicators of active bleeding, or
hematocrit, platelets, and impending complications.
clotting factors.

8. Administer medications as 8. Promotes prothrombin synthesis

ordered: Vitamin K IVTT q and coagulation.
8 hours.

9. Use small needles for 9. Minimizes damage to tissues,

injections or for blood- reducing risk of bleeding.
 drawing procedures.

Source: Nursing Care Plans:

Guidelines for Individualizing
Client Care Across the Lifespan, 9th
Edition.

Assessment Nursing Scientific Planning Intervention Rationale Evaluation

 Diagnosis Rationale

Subjective: Disturbed body With hepatic After an hour Goal Met:

“Aadi nanhuhubag image related to disorders, the of nursing Client was able
ngani iton akon mga biophysical bilirubin interventions, to verbalize
kamot tapos tiil. Dako changes as concentration in the client will understanding
guihapon iton akon evidenced by the blood is be able to: of changes.
tiyan.”, patient reports of negative abnormally INDEPENDENT:
verbalized. feelings about elevated, causing a. Verbalize 1. Assess changes in appearance 1. Provides information for
body. all the body understanding and the meaning these changes assessing impact of changes in
“Nandudulaw na ngani tissues, including of changes. have for patient and family. appearance on the patient and the
iton akon panit tapos sclerae and skin, to family.
mata.”, patient become tinged
verbalized. yellow or green- 2. Assess patient’s and family’s 2. Permits encouragement of those
yellow in color. previous coping strategies. coping strategies that are familiar to
“Mas tumambok ako patient and have been effective in
dida han akon the past.
pagkasakit.”, patient
verbalized. Source: Medical- 3. Assist patient in identifying 3. Recognition and
Surgical Nursing, previous practices that may acknowledgement of the harmful
12th Edition by have been harmful to self effects of these practices are
Objective: Brunner and (alcohol abuse). Involve patient necessary for identifying a healthier
Icteric sclerae noted. Suddarth. in goal-setting and provide lifestyle.
positive feedback for
Generalized jaundice accomplishments.
observed.
After a week 4. Discuss situation and 4. Client is very sensitive to body Goal Unmet:
Edema on both upper of nursing encourage verbalization of fears changes and may also feel guilt Client unable to
and lower extremities interventions and concerns. Explain when cause is related to alcohol. demonstrate
present. the client will: relationship between disease acceptance of
and signs and symptoms. self in the
a. Demonstrate present
acceptance of 5. Encourage family or 5. Participation in care helps them situation.
self in the significant others to verbalize feel useful and promotes trust
present feelings, visit freely, and between staffs, client, and family or
situation. participate in care. significant others.

6. Assist client or significant

others to cope with change in 6. Providing support can enhance
 appearance. the self-esteem and promote
client’s sense of control.
7. Provide care with a positive,
friendly attitude. 7. Caregivers need to make every
effort to help client feel valued as a
person.

Source: Nursing Care Plans:

Guidelines for Individualizing
Client Care Across the Lifespan, 9th
Edition.