NURSING CARE PLAN

Name of Patient: Mangku Kowlam Date Admitted: May 7, 2022 Chief Complaint: Hepatic Failure and Hypotension Case Number: 2

Age: 14 years old Gender: Male Civil Status: Single Address: Los Banos Laoang AP: Jonathan Mercado Raul Sy
 NURSING GOALS AND
ASSESSMENT RATIONALE NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES
Subjective Data: Fatigue in relation to Hepatic failure is associated Short Term Goals and Independent: Independent: Short term Goal and
deviation of metabolic with decrease in energy Objectives: 1. Establish Rapport to 1. To promote active Objectives:
“My son said that his head energy production due expenditure due to patient patient cooperation
to liver failure evident impairment in metabolism – Within 4 hours of providing 2. Promote rest and Within 24 hours of patient
hurts and is experiencing 2. Promote bed rest
nursing care, the patient will relaxation as available
joint and muscle pains” in fever, and statements metabolic energy care, desired outcomes are met
be able to:
of discomforts production. Additionally the energy is used for and patient is now able to:
 Report improve
“He’s also been saying associated with patient is at hypermetabolic sense of energy healing. Avoid activities  Report sense of
that he feels tired” lethargy and general state and is associated with  Show signs of and frequent upright improvement in
weakness. infection resulting in fever increased position as these are energy
Objective Data: which increases demands on engagement of believed to decrease  Show signs of
cellular repair. activities circulation to liver cells/ increased
3. Provide quite 3. For optimal healing, and engagement in
Temperature: 400C Long Term Goals and
environment and limit prevent sensory activities of daily
Objectives:
visitors overload that could living
Lethargy
disrupt patient’s
Within 4 days of nursing
intervention, the patient will: progression to healing
General Weakness
 Be able participate and promotes relaxation Long Term Goals and
in ADL with signs 4. Recommend patient for 4. This enables optimal Objectives:
of improvement and frequent position change respiratory function and
no assistance minimize pressures on Within 5 days of patient care,
 Verbalize factors vital areas and muscles the desired goals are now met
that causes fatigue 5. Helps in minimizing
5. Identify energy and the patient is:
 Verbalize ways on patient’s tiredness, and
energy conservation. conserving techniques  Able to participate in
and help patient with enables the patient to ADLs with signs of
ADLs feel better improvement and
6. Encourage use of stress 6. This promotes relaxation with no need for
management techniques and conserves energy. assistance
such as introduction of This also helps patient to  Able to verbalize
the patient’s favourite redirect attention and factors that can cause
song, or toy such would enhance fatigue
coping  Be able to identify
7. Don’t introduce tasks to 7. This allows extended ways in which energy
quickly to patient patient rest and reduce could be conserve
stress related to
receiving a lot of
information at once

Collaborative: Collaborative:
1. Monitor patient’s serial 1. Aids in determining
liver enzyme level appropriate levels of
activity
2. Assist patient with ADLs 2. Enable patient to use
or inpatient activities less effort and conserve
such as catharsis or energy