Subjective	Objective
Complaints of shortness of breath	Dyspnea; orthopnea; increased respiratory rate; decreased depth of breathing; decreased inspiratory/expiratory pressure; decreased minute ventilation; decreased vital capacity; nasal flaring; use of accessory muscles to breathe; assumption of three-point position; altered chest excursion; pursed-lip breathing; prolonged expiration phases

RISK FACTORS:

• Surgery

• Immobility

DESIRED OUTCOMES: The client will maintain an effective breathing pattern as evidenced by:

a. Normal rate and depth of respirations

b. Absence of dyspnea

NOC OUTCOMES: Respiratory status: ventilation

NIC INTERVENTIONS: Ventilation assistance; respiratory monitoring

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Collaborative Diagnosis RISK FOR ABSCESS FORMATION

Definition: An accumulation of pus in any area of the body

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbalization of pain in the surgical area	Redness, swelling, and/or warmth in the surgical area; fever; tachycardia; increased white blood cell (WBC) count

RISK FACTORS:

• Surgery

• Exposure to pathogens

DESIRED OUTCOMES: The client will not develop an abscess as evidenced by:

a. Gradual resolution of abdominal pain

b. Temperature declining toward normal

c. WBC count declining toward normal

NURSING ASSESSMENT

	RATIONALE
Assess for and report signs and symptoms of an abscess (e.g., increased or more constant abdominal pain, increase in temperature and pulse rate, further increase in WBC count).	Early recognition of signs and symptoms of an abscess allows for prompt intervention.

THERAPEUTIC INTERVENTIONS

Collaborative Diagnosis RISK FOR PERITONITIS

Definition: Inflammation of the peritoneum

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbalization of abdominal pain	Nausea and vomiting; distended and rigid abdomen; diminished or absent bowel sounds fever; tachypnea; increased WBC count

RISK FACTORS:

• Surgery

• Exposure to pathogens

DESIRED OUTCOMES: The client will not develop peritonitis as evidenced by:

a. Gradual resolution of abdominal pain

b. Soft, nondistended abdomen

c. Temperature declining toward normal

d. Stable vital signs

e. Absence of nausea and vomiting

f. Gradual return of normal bowel sounds

g. WBC count declining toward normal

NURSING ASSESSMENT

	RATIONALE
Assess for and report signs and symptoms of peritonitis (e.g., increase in severity of abdominal pain; generalized abdominal pain; rebound tenderness; distended, rigid abdomen; increase in temperature; tachycardia; tachypnea; hypotension; nausea; vomiting; continued diminished or absent bowel sounds; WBC count that increases or fails to decline toward normal).	Early recognition of the signs and symptoms of peritonitis allows for prompt intervention.

THERAPEUTIC INTERVENTIONS

Collaborative Diagnosis RISK FOR CONTINUED OBSTRUCTION OF BILE FLOW

Definition: Blockage of bile flow

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbalization of continued abdominal pain and nausea	Increased drainage from T tube; yellow-tinged skin; clay colored stools; dark amber urine

RISK FACTOR:

• Surgery

DESIRED OUTCOMES: The client will have resolution of bile flow obstruction within 7 to 10 days after surgery as evidenced by:

a. Decline in output of bile in T tube to less than 400 mL/day

b. Absence of pain, nausea, and feeling of fullness when T tube is clamped

c. Absence of jaundice, clay-colored stools, and dark amber urine

NURSING ASSESSMENT

	RATIONALE
Assess for and report signs and symptoms of continued bile flow obstruction (e.g., T tube draining more than 1000 mL in 24 hours; a marked increase in T-tube drainage after it has started to decline; persistent pain, nausea, or feeling of fullness when T tube is clamped; jaundice; clay-colored stools; dark amber urine).	Early recognition of the signs and symptoms of bile flow obstruction allows for prompt intervention.

THERAPEUTIC INTERVENTIONS

DISCHARGE TEACHING/CONTINUED CARE

Nursing Diagnosis DEFICIENT KNOWLEDGE NDx; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT NDx; OR INEFFECTIVE SELF-HEALTH MANAGEMENT^* NDx

Definition: Absence or deficiency of cognitive information

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbalizes inability to manage illness; verbalizes inability to follow prescribed regimen	Inaccurate follow through with instructions; inappropriate behaviors; experience of preventable complications of surgery

RISK FACTORS:

• Cognitive deficit

• Financial concerns

• Failure to take action to reduce risk factors for complications of surgery (if performed)

• Inability to care for oneself

• Difficulty in modifying personal habits and integrating treatments into lifestyle

NOC OUTCOMES: Knowledge: treatment regimen; knowledge: diet

NIC INTERVENTIONS: Health system guidance; teaching: prescribed diet; teaching: procedure/treatment; teaching: prescribed medication

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

CHOLELITHIASIS/CHOLECYSTITIS

Cholelithiasis refers to the presence of gallstones in the gallbladder. Factors that contribute to gallstone formation are abnormal bile composition; biliary stasis or slow emptying of the gallbladder resulting from factors such as fasting, pregnancy, prolonged parenteral nutrition, or an obstructive lesion in the biliary system; and inflammation of the gallbladder. Cholesterol stones are the most prevalent type of gallstone. They are most often associated with a high-cholesterol diet or cholesterol-lowering drugs and form when bile becomes supersaturated with cholesterol, which then precipitates and starts to form stones. Other components of bile that precipitate into stones are bile salts, bilirubin, calcium, and protein. Stones either remain in the gallbladder or migrate into the duct system where they may cause partial or complete obstruction. The severity of the client’s symptoms depends on the degree of bile flow obstruction.

Cholecystitis is inflammation of the gallbladder wall. Most cases of cholecystitis result from bile stasis, which is most commonly due to obstruction of the cystic duct by a gallstone. The bile trapped in the gallbladder acts as a chemical irritant causing inflammation and edema of the gallbladder wall. Cholecystitis in the absence of stones (acalculous cholecystitis) is thought to result from a buildup of mucus or sludge in the gallbladder associated with biliary stasis. This stasis can result from factors such as prolonged fasting or total parenteral nutrition, ischemia of the gallbladder associated with vasculitis, or bacterial invasion of the gallbladder via the blood or lymph system. After the period of acute inflammation, scarring often develops, resulting in loss of normal gallbladder function.

In most cases, the treatment of choice for symptomatic cholelithiasis and cholecystitis is cholecystectomy and choledocholithotomy if stones have migrated into the biliary duct system. A percutaneous cholecystostomy may be done to relieve symptoms if the client has severe symptoms and is a poor surgical risk. Nonsurgical treatment of gallstones includes endoscopic sphincterotomy with basket removal of stones, dissolution of stones using oral bile acids, percutaneous or endoscopic instillation of a dissolution agent into the gallbladder, and extracorporeal shockwave lithotripsy. These nonoperative modalities are only performed on a small percentage of patients (e.g., high-risk surgical candidates, persons who refuse surgery) because of the high incidence of recurrence of gallstones with nonsurgical treatments and the increasing popularity of laparoscopic surgery.

This care plan focuses on the adult client hospitalized with probable cholelithiasis and/or cholecystitis.

OUTCOME/DISCHARGE CRITERIA

The client will:

1. Have relief of severe pain

2. Tolerate prescribed diet

3. Have no signs and symptoms of complications

4. Verbalize an understanding of ways to reduce the risk for recurrent gallbladder attacks

5. State signs and symptoms to report to the health care provider

6. Verbalize an understanding of and a plan for adhering to recommended follow-up care including future appointments with health care provider and medications prescribed.

For a full, detailed care plan on this topic, go to http://evolve.elsevier.com/Haugen/careplanning/.

CIRRHOSIS

Cirrhosis is a chronic disease of the liver that occurs as a result of extensive destruction of the parenchymal cells in the liver. These cells are eventually replaced by fibrous scar tissue with subsequent change in the structure and functioning of the liver. The structural changes impair portal blood flow, which results in venous congestion in other organs and systems such as the spleen and gastrointestinal tract.

There are numerous causes of cirrhosis. More than half of the cases of cirrhosis are associated with alcohol and chronic viral hepatitis. Other causes of cirrhosis include exposure to toxic chemicals or drugs, hereditary metabolic disorders (e.g., alpha₁-antitrypsin deficiency, Wilson’s disease, hemochromatosis), heart failure, and conditions that cause persistent bile flow obstruction (e.g., primary biliary cirrhosis, primary sclerosing cholangitis). In approximately 15% to 20% of cases, no cause is identified.

All types of cirrhosis have similar signs and symptoms, which are manifestations of impaired liver function and the venous congestion that occurs with portal hypertension. Alcohol-related cirrhosis may have additional manifestations such as cerebral degeneration and demyelinating neuropathies that are thought to be a direct result of the toxic effects of alcohol or certain associated vitamin deficiencies. Treatment of cirrhosis is supportive and directed at slowing the progression of liver failure and reducing the incidence and/or severity of complications. The primary goals of treatment are to eliminate or manage the factors/conditions that contributed to the development of cirrhosis, provide a diet that is high in nutrients and will reduce the risk for further liver damage, and encourage rest to reduce the metabolic demands on the liver. A liver transplant may be indicated to treat end-stage liver disease.

This care plan focuses on the adult client with alcoholic (Laennec’s) cirrhosis hospitalized for management of increasing ascites and peripheral edema. Much of the information is applicable to clients receiving follow-up care in an extended care facility or home setting.

OUTCOME/DISCHARGE CRITERIA

The client will:

1. Have an adequate nutritional intake

2. Perform activities of daily living without extreme fatigue or dyspnea

3. Have a reduction in or resolution of ascites and edema

4. Have no evidence of life-threatening complications

5. Identify ways to prevent further liver damage

6. Verbalize an understanding of the rationale for and components of the recommended diet

7. Identify ways to reduce stress on or trauma to the esophageal blood vessels

8. Identify ways to prevent bleeding

9. Identify ways to reduce the risk of infection

10. Identify ways to relieve pruritus

11. State signs and symptoms to report to the health care provider

12. Identify community resources that can assist with home management and adjustment to lifestyle changes necessary for effective management of cirrhosis

13. Share concerns and feelings about the diagnosis of cirrhosis; prognosis; and effects of the disease process and its treatment on self-concept, lifestyle, and roles

14. Verbalize an understanding of and a plan for adhering to recommended follow-up care including future appointments with health care provider, medications prescribed, and activity level.

Nursing Diagnosis INEFFECTIVE BREATHING PATTERN NDx

Definition: Inspiration and/or expiration that does not provide adequate ventilation

• Decreased depth of respirations associated with:

• Weakness and fatigue

• Decreased lung compliance (distensibility) resulting from pleural effusion (hepatic hydrothorax) that occurs because of excess fluid volume and passage of ascitic fluid into the pleural space through a probable pressure-related defect in the diaphragm

• Restricted chest expansion resulting from positioning and pressure on the diaphragm as a result of ascites

CLINICAL MANIFESTATIONS:

Subjective	Objective
Complaints of shortness of breath	Dyspnea; orthopnea; increased respiratory rate; decreased depth of breathing; decreased inspiratory/expiratory pressure; decreased minute ventilation; decreased vital capacity; nasal flaring; use of accessory muscles to breathe; assumption of three-point position; altered chest excursion; pursed-lip breathing; prolonged expiration phases; increased anterior-posterior diameter

RISK FACTORS:

• Chronic illness

• Failure of body’s regulatory mechanisms

DESIRED OUTCOMES: The client will have an improved breathing pattern as evidenced by:

a. Normal rate and depth of respirations

b. Decreased dyspnea

c. Symmetrical chest excursion

NOC OUTCOMES: Respiratory status: ventilation

NIC INTERVENTIONS: Ventilation assistance; respiratory monitoring

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing/Collaborative Diagnosis RISK FOR EXCESS FLUID VOLUME NDx AND THIRD-SPACING

Definition: Risk for developing an imbalance of electrolytes and fluids in the intracellular and extracellular compartments of the body

• Inability of the liver to metabolize aldosterone

• Activation of the renin-angiotensin-aldosterone mechanism as a result of decreased renal blood flow (occurs because of a decrease in intravascular volume that results from vasodilation and from third-spacing and sequestration of fluid in the splanchnic system)

• Low plasma colloid osmotic pressure associated with hypoalbuminemia (a result of decreased hepatic synthesis of albumin and prolonged inadequate nutrition)

Increased pressure in the portal system and hepatic lymph system associated with blood flow backup resulting from structural changes in the liver

CLINICAL MANIFESTATIONS:

Subjective

Objective

Shortness of breath

Jugular venous distention; decreased hemoglobin (Hgb) and hematocrit (Hct); weight gain over short period; dyspnea; intake exceeds output; pleural effusion; orthopnea; S₃ heart sound; pulmonary congestion; change in respiratory pattern; change in mental status; B/P changes; pulmonary artery pressure changes; oliguria; specific gravity changes; azotemia; altered serum electrolyte levels; restlessness; anxiety; abnormal breath sounds (crackles); edema, may progress to anasarca; increased central venous pressure; positive hepatojugular reflex

RISK FACTORS:

• Hyperaldosteronism

• Poor nutritional status

• Portal hypertension

DESIRED OUTCOMES: The client will experience resolution of fluid and electrolyte imbalance fluid as evidenced by:

a. Decline in weight toward client’s normal weight

b. B/P and pulse rate within normal range for client and stable with position change

c. Absence or resolution of S₃ heart sound

d. Balanced intake and output

e. Usual mental status

f. Serum sodium level returning toward normal range

g. Decreased dyspnea, peripheral edema, and neck vein distention

h. Improved breath sounds

i. Resolution of ascites

NOC OUTCOMES: Fluid balance; fluid overload severity; electrolyte and acid-base balance

NIC INTERVENTIONS: Fluid monitoring; fluid/electrolyte management; electrolyte management: hyponatremia; electrolyte management: hypokalemia; hypervolemia management

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing/Collaborative Diagnosis RISK FOR HYPOKALEMIA

Definition: Below normal range for serum potassium levels

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbalization of nausea and muscle weakness	Cardiac dysrhythmias; electrocardiogram (ECG) reading showing ST-segment depression, T-wave inversion or flattening, and presence of U waves; postural hypotension; vomiting; abdominal distention; hypoactive or absent bowel sounds; low serum potassium level

RISK FACTORS:

• Chronic illness

• Failure of regulatory mechanisms

• Medication regimen

DESIRED OUTCOMES: The client will maintain a safe serum potassium level as evidenced by:

a. Regular pulse at 60 to 100 beats/min

b. B/P within normal range for client and stable with position change

c. Usual muscle tone and strength

d. Absence of nausea and vomiting

e. Soft, nondistended abdomen with normal bowel sounds

f. Normal ECG reading

g. Serum potassium level within normal range

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Collaborative Diagnosis RISK FOR HYPONATREMIA

Definition: Below normal range for serum sodium levels

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbalization of nausea and abdominal cramps; feelings of lethargy and weakness	Vomiting; confusion; seizures; decreased serum sodium level

RISK FACTORS:

• Chronic illness

• Failure of regulatory mechanisms

• Medication regimen

DESIRED OUTCOMES: The client will maintain a safe serum sodium level as evidenced by:

a. Absence of nausea, vomiting, and abdominal cramps

b. Usual mental status

c. Usual muscle strength

d. Absence of seizure activity

e. Serum sodium level within normal range

NURSING ASSESSMENT

	RATIONALE
Assess for and report signs and symptoms of hyponatremia (e.g., nausea, vomiting, abdominal cramps, lethargy, confusion, weakness, seizures).	Early recognition of signs and symptoms of hyponatremia allows for prompt treatment.

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS NDx

Definition: Inadequate intake or insufficient nutrition to meet the body’s metabolic needs

• Reduced metabolism and storage of nutrients by the liver associated with a reduction of functional liver tissue

• Malabsorption of fats and fat-soluble vitamins associated with impaired bile production and flow.

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbalization of lack of appetite; fatigue; sore buccal membrane irritability; poor self-esteem	Loss of weight with adequate food intake; body weight 20% or more under ideal weight; inflamed buccal cavity; capillary fragility; pale conjunctiva and mucous membranes; poor muscle tone; excessive hair loss; amenorrhea

RISK FACTORS:

• Chronic illness

• Anorexia

• Poor nutritional status

• Poor dietary habits

DESIRED OUTCOMES: The client will maintain an adequate nutritional status as evidenced by:

a. Dry weight approaching normal for the client (dry weight achieved after fluid volume excess has been resolved)

b. Normal BUN and serum albumin, prealbumin, Hct, and Hgb levels, and normal lymphocyte count

c. Improved strength and activity tolerance

d. Healthy oral mucous membrane

NOC OUTCOMES: Nutritional status

NIC INTERVENTIONS: Nutritional monitoring; nutritional counseling; nutritional management; nutritional therapy

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis IMPAIRED COMFORT NDx (PRURITUS)

Definition: Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental, and social dimensions

CLINICAL MANIFESTATIONS:

Subjective	Objective
Complaint of skin itching	Persistent scratching or rubbing of skin

RISK FACTOR:

• Chronic illness

DESIRED OUTCOMES: The client will experience relief of pruritus as evidenced by:

a. Verbalization of same

b. No scratching or rubbing of skin

NOC OUTCOMES: Comfort level; symptom control

NIC INTERVENTIONS: Pruritus management

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis IMPAIRED COMFORT NDx (DYSPEPSIA)

Definition: Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental, and social dimensions

• Reflux of gastric contents associated with increased intra-abdominal pressure resulting from ascites

• Impaired gastrointestinal functioning associated with venous congestion in the gastrointestinal tract (portal hypertensive gastropathy)

• Esophagitis/gastritis associated with the irritant effect of chronic alcohol ingestion on the esophageal and gastric mucosa

CLINICAL MANIFESTATIONS:

Subjective	Objective
Complaints of stomach discomfort; heartburn; nausea; or feeling of fullness or bloating	Frequent eructation

RISK FACTORS:

• Impaired digestive processes

• Alcohol ingestion

• Portal hypertension

DESIRED OUTCOME: The client will verbalize relief of dyspepsia.

NOC OUTCOMES: Comfort level

NIC INTERVENTIONS: Flatulence reduction; nausea management

NURSING ASSESSMENT

	RATIONALE
Assess client for signs and symptoms of dyspepsia (e.g., reports of epigastric discomfort, heartburn, nausea, or feeling of fullness or bloating; frequent eructation).	Early recognition of signs and symptoms of dyspepsia allows for prompt intervention.
Assess which foods/fluids contribute to dyspepsia (client usually reports an intolerance of fatty foods).	Helps client determine which foods to avoid.

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis ACTIVITY INTOLERANCE NDx

Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities

• Decreased production of red blood cells (RBCs) resulting from a decreased intake and absorption of vitamins and minerals and an inability of the liver to store vitamins and minerals

• Excessive RBC destruction resulting from hypersplenism (if venous congestion has resulted in splenomegaly, the spleen will destroy RBCs faster than usual)

• Blood loss if bleeding has occurred

• Loss of muscle mass, tone, and strength associated with malnutrition and disuse if mobility has been limited for an extended period

• Decrease in available energy associated with inability of the liver to metabolize glucose, fats, and proteins properly

• Difficulty resting and sleeping associated with dyspnea, discomfort, frequent assessments and treatments, fear, anxiety, and unfamiliar environment

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbal report of fatigue or weakness	Abnormal heart rate or B/P response to activity; exertional discomfort or dyspnea; ECG changes reflecting dysrhythmias or ischemia; unable to speak during physical activity

RISK FACTORS:

• Chronic illness

• Poor nutritional status

• Immobility

• Impaired digestive processes

DESIRED OUTCOMES: The client will demonstrate an increased tolerance for activity as evidenced by:

a. Verbalization of feeling less fatigued and weak

b. Ability to perform activities of daily living without exertional dyspnea, chest pain, diaphoresis, dizziness, and significant changes in vital signs

NOC OUTCOMES: Rest; energy conservation; activity tolerance

NIC INTERVENTIONS: Energy management; oxygen therapy; nutrition management; sleep enhancement

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Collaborative/Nursing Diagnosis ACUTE AND CHRONIC CONFUSION NDx

Definition:

Acute: Abrupt onset of reversible disturbances of consciousness, attention, cognition, and perception

Chronic: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli; decreased capacity for intellectual thought processes; and manifested by disturbances of memory, orientation, or behavior

CLINICAL MANIFESTATIONS:

Subjective	Objective
N/A	Inaccurate interpretation of environment and time; memory loss; altered mood states (e.g., liability, hostility, irritability, inappropriate affect); inability to make decisions or problem solve; changes in attention span; disorientation; inappropriate social behavior

RISK FACTORS:

• Alcohol use

• Inability of body to remove toxins

• Poor nutritional status

DESIRED OUTCOMES: The client will demonstrate decreased confusion as evidenced by:

a. Improved ability to grasp ideas

b. Improved memory

c. Longer attention span

d. Absence or resolution of inappropriate behavior

e. Oriented to person, place, and time

NOC OUTCOMES: Cognitive orientation; distorted thought process; neurological status; agitation; sleep level; safety behavior; information processing

NIC INTERVENTIONS: Environmental management; behavioral management

NURSING ASSESSMENT

	RATIONALE
Assess for episodes of disorientation to person, place, and time; episodes of inappropriate behavior; impaired decision-making ability; impaired attention span	Early recognition of signs and symptoms of confusion allows for prompt intervention.

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Tags: Ulrich Canales Nursing Care Planning Guides

Feb 11, 2017 | Posted by admin in NURSING | Comments Off

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Nursing Care of the Client with Disturbances of the Liver, Biliary Tract, and Pancreas

Nursing Care of the Client with Disturbances of the Liver, Biliary Tract, and Pancreas

Collaborative Diagnosis RISK FOR PERITONITIS

Nursing Diagnosis DEFICIENT KNOWLEDGE NDx; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT NDx; OR INEFFECTIVE SELF-HEALTH MANAGEMENT* NDx

CHOLELITHIASIS/CHOLECYSTITIS

Nursing/Collaborative Diagnosis RISK FOR EXCESS FLUID VOLUME NDx AND THIRD-SPACING

Nursing Diagnosis IMPAIRED COMFORT NDx (PRURITUS)

Nursing Diagnosis IMPAIRED COMFORT NDx (DYSPEPSIA)

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Nursing Diagnosis DEFICIENT KNOWLEDGE NDx; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MANAGEMENT NDx; OR INEFFECTIVE SELF-HEALTH MANAGEMENT^* NDx