ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE DATA: Impaired bowel STG: Assess the frequency of bowel pattern Assessment aids in diagnosis & STG:
 Change in bowel elimination After 8 hours of nursing providing appropriate interventions
habits like alternate pattern r/t change intervention, the patient will In case of diarrhea, asses the color, To replace the fluids according to the After 8 hours of nursing intervention,
episodes of diarrhea in bowel habits as be able to: consistency & frequency of stools loss short term goal is fully achieved as
& constipation alternate episodes  evidenced by:
 Hematemesis of constipation & Administer oral rehydration solution To replace the fluids & prevent
diarrhea LTG: after every loose stools dehydration 
 Dyspepsia
 Abdominal bloating secondary to After 3 days of nursing Advice the client to take the fluids as To prevent constipation & dehydration
decreased intervention the patient will be LTG:
& pain advised
 Black & tarry stools metabolic function able to: After 3 days of nursing intervention,
of the liver  Client will be able to Advice the client to take carbohydrate To treat constipation long term goal is fully achieved as
OBJECTIVE DATA: maintain a normal & fiber rich foods like wheat bran &
evidenced by:
 Fetor Hepaticus bowel elimination oranges as prescribed
(Sweet odor of pattern with regular Administer dulcolax syrup or To increase peristalsis & aid in stool  Client maintained a normal
breath) bowel habits suppositories as prescribed elimination bowel elimination pattern
 Distended abdomen Administer proctolysis enema as To eliminate the stools with regular bowel habits
 Pain in the right prescribed in case of constipation
hypochondriac region Provide bowel wash with laxatives To eliminate the stools & prevent
of abdomen once every 6 hours in case of sever hepatic encephalopathy
 Loose stools or black constipation
& tarry stools/ Administer IV fluids like colloids To prevent dehydration & maintain
straining at stools &crystalloids as prescribed fluid volume status
 Irregular bowel Advice to take low protein diet As the liver cannot metabolize the
sounds protein they can build up the intestinal
 Stools for occult ammonia and cause encephalopathy
Blood Positive Place the client on molecular To temporarily support the liver
 Abdominal palpation absorbent recirculating system if function and improve the bowel habits
shows hepatomegaly needed of the client
 Presence of anal/ Advice the client on the need for liver To replace the liver function and aid in
sacral edema transplantation and prepare for the metabolism of foods thereby improves
 Hypoalbuminemia surgical procedure, if indicated in end the bowel pattern
 Elevated liver of stage liver disease
enzymes
 Liver ultrasound
reveals fatty or
fibrous scarring of the
liver
 Liver Biopsy shows
fibrosis & scarring of
Liver tissue
a