Outcomes (NOC)	Interventions (NIC) and Rationales
Nutritional Status • Nutrient intake _____ • Food intake _____ • Fluid intake _____ • Weight/height ratio _____ • Energy _____ Measurement Scale 1 = Severe deviation from normal range 2 = Substantial deviation from normal range 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range Nausea and Vomiting Controls • Uses preventive measures _____ • Avoids disagreeable odors _____ • Reports uncontrolled symptoms to health professional ____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Nutrition Therapy • Complete a nutritional assessment to determine baseline nutritional state. • Monitor food/fluid ingested and calculate daily caloric intake so appropriate interventions can be planned. • Determine, in collaboration with the dietitian, the number of calories and type of nutrients needed so sufficient nutritional requirements can be provided. • Present food in an attractive, pleasing manner, giving consideration to color, texture, and variety to stimulate patient’s appetite. Nausea Management • Teach the use of nondrug techniques (e.g., biofeedback, hypnosis, relaxation, guided imagery, music therapy, distraction, acupressure) to manage nausea without use of drugs requiring hepatic metabolism. • Encourage eating small amounts of food that are appealing to the nauseated person to increase nutrition intake. • Monitor effects of nausea management throughout to determine changes in status. • Weigh regularly to monitor weight loss secondary to poor appetite • Use frequent oral hygiene to promote comfort unless it stimulates nausea.

Outcomes (NOC)

Interventions (NIC) and Rationales

Nutritional Status

• Nutrient intake _____

• Food intake _____

• Fluid intake _____

• Weight/height ratio _____

• Energy _____

Measurement Scale

1 = Severe deviation from normal range

2 = Substantial deviation from normal range

3 = Moderate deviation from normal range

4 = Mild deviation from normal range

5 = No deviation from normal range

Nausea and Vomiting Controls

• Uses preventive measures _____

• Avoids disagreeable odors _____

• Reports uncontrolled symptoms to health professional ____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Nutrition Therapy

• Complete a nutritional assessment to determine baseline nutritional state.

• Monitor food/fluid ingested and calculate daily caloric intake so appropriate interventions can be planned.

• Determine, in collaboration with the dietitian, the number of calories and type of nutrients needed so sufficient nutritional requirements can be provided.

• Present food in an attractive, pleasing manner, giving consideration to color, texture, and variety to stimulate patient’s appetite.

Nausea Management

• Teach the use of nondrug techniques (e.g., biofeedback, hypnosis, relaxation, guided imagery, music therapy, distraction, acupressure) to manage nausea without use of drugs requiring hepatic metabolism.

• Encourage eating small amounts of food that are appealing to the nauseated person to increase nutrition intake.

• Monitor effects of nausea management throughout to determine changes in status.

• Weigh regularly to monitor weight loss secondary to poor appetite

• Use frequent oral hygiene to promote comfort unless it stimulates nausea.

Nursing Diagnosis

Activity intolerance related to fatigue and weakness as evidenced by verbal report of fatigue or weakness, altered response to activity

Patient Goals

1. Demonstrates gradual increase in activity tolerance

2. Reports ability to perform daily activities with scheduled rest periods

Outcomes (NOC)	Interventions (NIC) and Rationales
Energy Conservation • Recognizes energy limitations _____ • Reports adequate endurance for activity _____ • Balances activity and rest _____ • Uses energy conservation techniques _____ • Organizes activities to conserve energy _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Energy Management • Determine patient’s physical limitations for baseline comparison. • Assist patient to schedule rest periods to prevent stress on liver function. • Encourage patient to choose activities that gradually build endurance so previous activity pattern can be resumed. • Limit environmental stimuli (e.g., light and noise) to facilitate relaxation. • Instruct patient/caregiver to recognize signs and symptoms of fatigue that require reduction in activity to promote self-management. • Teach activity organization and time management techniques to prevent fatigue. • Monitor patient for evidence of excess physical and emotional fatigue to prevent setback of activity progression.

Outcomes (NOC)

Interventions (NIC) and Rationales

Energy Conservation

• Recognizes energy limitations _____

• Reports adequate endurance for activity _____

• Balances activity and rest _____

• Uses energy conservation techniques _____

• Organizes activities to conserve energy _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Energy Management

• Determine patient’s physical limitations for baseline comparison.

• Assist patient to schedule rest periods to prevent stress on liver function.

• Encourage patient to choose activities that gradually build endurance so previous activity pattern can be resumed.

• Limit environmental stimuli (e.g., light and noise) to facilitate relaxation.

• Instruct patient/caregiver to recognize signs and symptoms of fatigue that require reduction in activity to promote self-management.

• Teach activity organization and time management techniques to prevent fatigue.

• Monitor patient for evidence of excess physical and emotional fatigue to prevent setback of activity progression.

Nursing Diagnosis

Risk for impaired liver function related to viral infection

Patient Goal

Maintains liver function throughout infectious process adequate to meet physiologic needs

Outcomes (NOC)	Interventions (NIC) and Rationales
Knowledge: Disease Process • Risk factors _____ • Effects of disease _____ • Strategies to minimize disease progression _____ • Potential complications of disease _____ • Signs and symptoms of complications _____ • Precautions to prevent complications of disease _____ Measurement Scale 1 = No knowledge 2 = Limited knowledge 3 = Moderate knowledge 4 = Substantial knowledge 5 = Extensive knowledge	Teaching: Disease Process • Explain pathophysiology of the disease and how it relates to anatomy and physiology. • Describe rationale behind management/therapy/treatment recommendations so that appropriate follow-up care will be planned and carried out. • Describe possible chronic complications to identify the risk for liver impairment. • Discuss lifestyle changes that may be required to prevent further complications and/or control the disease (e.g., avoidance of alcohol, infection control measures). • Explore possible resources/support for long-term disease management. • Instruct patient on which signs and symptoms (e.g., bleeding gums, blood in stools) to report to health care provider to enable prompt intervention. • Instruct patient on measures to control/minimize symptoms to enable liver to repair itself and prevent relapse.

Outcomes (NOC)

Interventions (NIC) and Rationales

Knowledge: Disease Process

• Risk factors _____

• Effects of disease _____

• Strategies to minimize disease progression _____

• Potential complications of disease _____

• Signs and symptoms of complications _____

• Precautions to prevent complications of disease _____

Measurement Scale

1 = No knowledge

2 = Limited knowledge

3 = Moderate knowledge

4 = Substantial knowledge

5 = Extensive knowledge

Teaching: Disease Process

• Explain pathophysiology of the disease and how it relates to anatomy and physiology.

• Describe rationale behind management/therapy/treatment recommendations so that appropriate follow-up care will be planned and carried out.

• Describe possible chronic complications to identify the risk for liver impairment.

• Discuss lifestyle changes that may be required to prevent further complications and/or control the disease (e.g., avoidance of alcohol, infection control measures).

• Explore possible resources/support for long-term disease management.

• Instruct patient on which signs and symptoms (e.g., bleeding gums, blood in stools) to report to health care provider to enable prompt intervention.

• Instruct patient on measures to control/minimize symptoms to enable liver to repair itself and prevent relapse.

^*Nursing diagnoses listed in order of priority.

eNursing Care Plan 44-2 Patient With Cirrhosis

Nursing Diagnosis*

Imbalanced nutrition: less than body requirements related to anorexia, impaired utilization and storage of nutrients, nausea, and loss of nutrients from vomiting as evidenced by lack of interest in food, aversion to eating, reported inadequate food intake

Nursing Diagnosis

Impaired skin integrity related to peripheral edema, ascites, and pruritus as evidenced by complaints of itching; areas of excoriation due to scratching; taut, shiny skin over edematous areas; and/or areas of skin breakdown

Patient Goal

Maintains skin integrity with relief of edema and pruritus

Outcomes (NOC)	Interventions (NIC) and Rationales
Tissue Integrity: Skin and Mucous Membranes • Skin integrity _____ • Elasticity _____ • Texture _____ • Hydration _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	Pruritus Management • Instruct patient to keep fingernails trimmed short to prevent excoriation due to pruritus secondary to deposit of bile salts in skin. • Apply medicated creams and lotions to relieve itching, avoiding use of systemic drugs that require liver metabolism. Skin Care: Topical Treatments • Inspect skin daily for those at risk of breakdown because edematous tissues are easily traumatized and subject to breakdown. • Provide support to edematous areas (e.g., pillows under arms and scrotal support). • Turn the immobilized patient at least every 2 hr to reduce risk of skin breakdown in dependent areas. • Keep bed linen clean, dry, and wrinkle free to protect skin from irritation. • Refrain from using an alkaline soap on the skin to prevent additional irritation of the skin.

Outcomes (NOC)

Interventions (NIC) and Rationales

Tissue Integrity: Skin and Mucous Membranes

• Skin integrity _____

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

Pruritus Management

• Instruct patient to keep fingernails trimmed short to prevent excoriation due to pruritus secondary to deposit of bile salts in skin.

• Apply medicated creams and lotions to relieve itching, avoiding use of systemic drugs that require liver metabolism.

Skin Care: Topical Treatments

• Inspect skin daily for those at risk of breakdown because edematous tissues are easily traumatized and subject to breakdown.

• Provide support to edematous areas (e.g., pillows under arms and scrotal support).

• Turn the immobilized patient at least every 2 hr to reduce risk of skin breakdown in dependent areas.

• Keep bed linen clean, dry, and wrinkle free to protect skin from irritation.

• Refrain from using an alkaline soap on the skin to prevent additional irritation of the skin.

Nursing Diagnosis

Excess fluid volume related to portal hypertension and hyperaldosteronism as evidenced by weight gain, dependent edema, ascites

Patient Goals

1. Experiences normalization of fluid balance as a result of medical and nursing interventions

2. Maintains blood pressure and urinary output within normal limits

Outcomes (NOC)	Interventions (NIC) and Rationales
Fluid Overload Severity • Ascites _____ • Increased abdominal girth _____ • Generalized edema _____ • Increased blood pressure _____ • Increased body weight _____ • Decreased urinary output _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Hypervolemia Management • Weigh patient daily and monitor trends to evaluate effectiveness of treatment. • Administer prescribed diuretics to prevent fluid retention and promote diuresis. • Monitor intake and output to maintain necessary fluid restrictions and assess renal function. • Monitor changes in peripheral edema to determine patient’s response to treatment. Fluid/Electrolyte Management • Provide prescribed diet appropriate for specific fluid or electrolyte imbalance (e.g., low-sodium, fluid-restricted, low-protein, and no added salt) to prevent additional fluid retention. • Obtain laboratory specimens for monitoring of altered fluid or electrolyte levels (e.g., hematocrit, BUN, protein, sodium, and potassium levels) to evaluate effectiveness of treatment.

Outcomes (NOC)

Interventions (NIC) and Rationales

Fluid Overload Severity

• Ascites _____

• Increased abdominal girth _____

• Generalized edema _____

• Increased blood pressure _____

• Increased body weight _____

• Decreased urinary output _____

Hypervolemia Management

• Weigh patient daily and monitor trends to evaluate effectiveness of treatment.

• Administer prescribed diuretics to prevent fluid retention and promote diuresis.

• Monitor intake and output to maintain necessary fluid restrictions and assess renal function.

• Monitor changes in peripheral edema to determine patient’s response to treatment.

Fluid/Electrolyte Management

• Provide prescribed diet appropriate for specific fluid or electrolyte imbalance (e.g., low-sodium, fluid-restricted, low-protein, and no added salt) to prevent additional fluid retention.

• Obtain laboratory specimens for monitoring of altered fluid or electrolyte levels (e.g., hematocrit, BUN, protein, sodium, and potassium levels) to evaluate effectiveness of treatment.

Nursing Diagnosis

Ineffective self-health management related to ineffective coping and abuse of alcohol as evidenced by observed inability to take responsibility for health and failure to take action to reduce risk factors

Patient Goals

1. Acknowledges a substance abuse problem

2. Participates in an alcohol treatment program

3. Achieves abstinence of alcohol

Outcomes (NOC)	Interventions (NIC) and Rationales
Alcohol Abuse Cessation Behaviors • Expresses willingness to stop alcohol use _____ • Commits to alcohol elimination strategies _____ • Uses effective coping mechanisms _____ • Adjusts lifestyle to promote alcohol elimination _____ • Obtains assistance from health professional _____ • Uses available support groups _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated Health Beliefs: Perceived Control • Belief that own decisions control health outcomes _____ • Belief that own actions control health outcomes _____ • Perceived responsibility for health decisions _____ Measurement Scale 1 = Very weak 2 = Weak 3 = Moderate 4 = Strong 5 = Very strong	Substance Use Treatment • Encourage patient to take control over behavior to change undesired behaviors. • Discuss with patient the impact of substance use on medical condition and general health to promote acknowledgment of consequences of use. • Assist patient to learn alternative methods of coping with stress or emotional distress to reduce substance use. • Identify support groups in the community for long-term substance abuse treatment to promote continued abstinence. Self-Responsibility Facilitation • Hold patient responsible for own behavior to facilitate responsible behaviors. • Discuss with patient the extent of responsibility for present health status. • Discuss consequences of not dealing with own responsibilities to emphasize realistic outcomes. • Set limits on manipulative behaviors to prevent attempts to shift responsibilities. • Refrain from arguing or bargaining about the established limits with the patient to prevent avoidance of responsibility. • Provide positive feedback for accepting additional responsibility and/or behavior change to reinforce desired behaviors.

Outcomes (NOC)

Interventions (NIC) and Rationales

Alcohol Abuse Cessation Behaviors

• Expresses willingness to stop alcohol use _____

• Commits to alcohol elimination strategies _____

• Uses effective coping mechanisms _____

• Adjusts lifestyle to promote alcohol elimination _____

• Obtains assistance from health professional _____

• Uses available support groups _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Health Beliefs: Perceived Control

• Belief that own decisions control health outcomes _____

• Belief that own actions control health outcomes _____

• Perceived responsibility for health decisions _____

Substance Use Treatment

• Encourage patient to take control over behavior to change undesired behaviors.

• Discuss with patient the impact of substance use on medical condition and general health to promote acknowledgment of consequences of use.

• Assist patient to learn alternative methods of coping with stress or emotional distress to reduce substance use.

• Identify support groups in the community for long-term substance abuse treatment to promote continued abstinence.

Self-Responsibility Facilitation

• Hold patient responsible for own behavior to facilitate responsible behaviors.

• Discuss with patient the extent of responsibility for present health status.

• Discuss consequences of not dealing with own responsibilities to emphasize realistic outcomes.

• Set limits on manipulative behaviors to prevent attempts to shift responsibilities.

• Refrain from arguing or bargaining about the established limits with the patient to prevent avoidance of responsibility.

• Provide positive feedback for accepting additional responsibility and/or behavior change to reinforce desired behaviors.

Nursing Diagnosis

Dysfunctional family processes related to abuse of alcohol and inadequate coping skills as evidenced by deterioration in family relationships, family denial, neglected obligations, inability to accept and receive help appropriately

Patient Goals

1. Family confronts problems and involves family members in decision making

2. Family uses available social support for treatment of alcohol abuse

Outcomes (NOC)	Interventions (NIC) and Rationales
Family Coping • Confronts family problems _____ • Uses strategies to manage family conflict _____ • Establishes family priorities _____ • Shares responsibility for family tasks _____ • Uses available family support system _____ • Involves family members in decision making _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Family Therapy • Determine family communication pattern to identify appropriate interventions. • Identify family strengths/resources to determine appropriate interventions. • Help members prioritize and select the most immediate family issue to address. • Help family enhance existing positive coping strategies for use in promoting coping. • Help family set goals toward a more competent way of handling dysfunctional behavior. • Accept the family’s values in a nonjudgmental manner. • Monitor for adverse therapeutic responses in order to intervene as necessary.

Outcomes (NOC)

Interventions (NIC) and Rationales

Family Coping

• Confronts family problems _____

• Uses strategies to manage family conflict _____

• Establishes family priorities _____

• Shares responsibility for family tasks _____

• Uses available family support system _____

• Involves family members in decision making _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Family Therapy

• Determine family communication pattern to identify appropriate interventions.

• Identify family strengths/resources to determine appropriate interventions.

• Help members prioritize and select the most immediate family issue to address.

• Help family enhance existing positive coping strategies for use in promoting coping.

• Help family set goals toward a more competent way of handling dysfunctional behavior.

• Accept the family’s values in a nonjudgmental manner.

• Monitor for adverse therapeutic responses in order to intervene as necessary.

Collaborative Problems

Potential Complication

Hemorrhage related to bleeding tendency secondary to altered clotting factors and rupture of esophageal or gastric varices

Nursing Goals	Nursing Interventions and Rationales
• Monitor for signs of hemorrhage • Initiate appropriate medical and nursing interventions	• Monitor for hemorrhage by assessing for epistaxis, purpura, petechiae, easy bruising, gingival bleeding, hematuria, heavy menstrual bleeding, melena, or frank bleeding from body orifices because liver disease results in impaired synthesis of clotting factors. • Monitor circulatory status: BP, skin color, skin temperature, heart rate and rhythm, presence and quality of peripheral pulses, and capillary refill for early detection of hypovolemic shock. • Provide gentle nursing care to minimize the risk of tissue trauma. • Use smallest-gauge needle possible when giving injections or drawing blood specimens and apply gentle but prolonged pressure to injection sites to minimize risk of bleeding into tissue. • Advise use of soft-bristle toothbrush and avoidance of irritating food to reduce injury to highly vascular mucous membranes. • Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing to reduce risk of hemorrhage at these sites. • Monitor laboratory results (hematocrit, hemoglobin, and prothrombin time) as indicators of anemia, active bleeding, or impending clotting problems.

Nursing Goals

Nursing Interventions and Rationales

• Monitor for signs of hemorrhage

• Initiate appropriate medical and nursing interventions

• Monitor for hemorrhage by assessing for epistaxis, purpura, petechiae, easy bruising, gingival bleeding, hematuria, heavy menstrual bleeding, melena, or frank bleeding from body orifices because liver disease results in impaired synthesis of clotting factors.

• Monitor circulatory status: BP, skin color, skin temperature, heart rate and rhythm, presence and quality of peripheral pulses, and capillary refill for early detection of hypovolemic shock.

• Provide gentle nursing care to minimize the risk of tissue trauma.

• Use smallest-gauge needle possible when giving injections or drawing blood specimens and apply gentle but prolonged pressure to injection sites to minimize risk of bleeding into tissue.

• Advise use of soft-bristle toothbrush and avoidance of irritating food to reduce injury to highly vascular mucous membranes.

• Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing to reduce risk of hemorrhage at these sites.

• Monitor laboratory results (hematocrit, hemoglobin, and prothrombin time) as indicators of anemia, active bleeding, or impending clotting problems.

Potential Complication

Hepatic encephalopathy related to increased serum levels of ammonia due to inability of liver to convert accumulating ammonia to urea for renal excretion

Nursing Goals	Nursing Interventions and Rationales
• Monitor for signs of hepatic encephalopathy • Report deviation from acceptable parameters • Carry out appropriate medical and nursing interventions	• Monitor for encephalopathy (assess patient’s general behavior, orientation to time and place, speech, blood pH, and ammonia levels) caused by toxic effects of ammonia on nervous system. • Encourage fluids (if not restricted) and administer medications as ordered to decrease ammonia production and absorption from the bowel and to promote bowel elimination of ammonia. • Limit physical activity because exercise produces ammonia as a by-product of protein metabolism.

Nursing Goals

Nursing Interventions and Rationales

• Monitor for signs of hepatic encephalopathy

• Report deviation from acceptable parameters

• Carry out appropriate medical and nursing interventions

• Monitor for encephalopathy (assess patient’s general behavior, orientation to time and place, speech, blood pH, and ammonia levels) caused by toxic effects of ammonia on nervous system.

• Encourage fluids (if not restricted) and administer medications as ordered to decrease ammonia production and absorption from the bowel and to promote bowel elimination of ammonia.

• Limit physical activity because exercise produces ammonia as a by-product of protein metabolism.

**Outcomes and interventions for this nursing diagnosis for the patient with cirrhosis are presented in eNCP 44-1,the Patient With Acute Viral Hepatitis.

BUN, blood urea nitrogen.

^*Nursing diagnoses listed in order of priority.

eNursing Care Plan 44-3 Patient With Acute Pancreatitis

Nursing Diagnosis *

Deficient fluid volume related to nausea, vomiting, restricted oral intake, and fluid shift into the retroperitoneal space as evidenced by decreased urine output, decreased blood pressure, increased heart rate, decreased peripheral pulse volume, thirst, and dry skin and mucous membranes

Patient Goal

Maintains fluid and electrolyte balance within normal limits

Outcomes (NOC)	Interventions (NIC) and Rationales
Fluid Balance • Blood pressure _____ • Radial pulse rate ____ • Moist mucous membranes _____ • Peripheral pulses _____ • 24-hour intake and output balance _____ • Urine specific gravity _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised • Ascites _____ • Muscle cramps ____ • Adventitious lung sounds _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Vomiting Management • Ensure that effective antiemetic drugs are given to prevent vomiting when possible to reduce fluid loss by preventing vomiting. • Measure or estimate emesis volume as indicators of replacement needs and effectiveness of treatment. Fluid/Electrolyte Management • Obtain laboratory specimens for monitoring of altered fluid or electrolyte levels (e.g., hematocrit, blood urea nitrogen [BUN], protein, sodium, and potassium), as appropriate to evaluate effectiveness of treatment. • Maintain intravenous solution containing electrolytes at a constant flow rate to prevent fluid or electrolyte overload. • Consult physician if signs and symptoms of fluid and/or electrolyte imbalance persist or worsen because these may indicate development of complications.

Outcomes (NOC)

Interventions (NIC) and Rationales

Fluid Balance

• Blood pressure _____

• Radial pulse rate ____

• Moist mucous membranes _____

• Peripheral pulses _____

• 24-hour intake and output balance _____

• Urine specific gravity _____

Measurement Scale

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromised

5 = Not compromised

• Ascites _____

• Muscle cramps ____

• Adventitious lung sounds _____

• Ensure that effective antiemetic drugs are given to prevent vomiting when possible to reduce fluid loss by preventing vomiting.

• Measure or estimate emesis volume as indicators of replacement needs and effectiveness of treatment.

Fluid/Electrolyte Management

• Obtain laboratory specimens for monitoring of altered fluid or electrolyte levels (e.g., hematocrit, blood urea nitrogen [BUN], protein, sodium, and potassium), as appropriate to evaluate effectiveness of treatment.

• Maintain intravenous solution containing electrolytes at a constant flow rate to prevent fluid or electrolyte overload.

• Consult physician if signs and symptoms of fluid and/or electrolyte imbalance persist or worsen because these may indicate development of complications.

Nursing Diagnosis

Risk for electrolyte imbalance related to fluid imbalances, altered pancreatic secretion, and third fluid spacing

Patient Goal

Maintains normal electrolyte balance

Outcomes (NOC)	Interventions (NIC) and Rationales
Electrolyte and Acid-Base Balance • Serum calcium _____ • Serum magnesium _____ • Serum potassium _____ • Serum pH _____ • Serum glucose _____ • Sensation in extremities _____ Measurement Scale 1 = Severe deviation from normal range 2 = Substantial deviation from normal range 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range • Muscle cramps _____ • Paresthesias _____ • Impaired cognition _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Electrolyte Management: Hypocalcemia • Monitor for clinical manifestations of hypocalcemia (e.g., tetany [classic sign]; tingling in tips of fingers, feet, or mouth; spasms of muscles in face or extremities; Trousseau’s sign; Chvostek’s sign; altered deep tendon reflexes; seizures [late sign]) to provide appropriate intervention. • Monitor for central nervous system (CNS) manifestations of hypocalcemia (e.g., personality disturbances, anxiety, irritability, depression, and psychosis). • Monitor for electrolyte imbalances associated with hypocalcemia (e.g., hyperphosphatemia, hypomagnesemia), and alkalosis to provide appropriate intervention. • Administer appropriate prescribed calcium salt (e.g., calcium carbonate, calcium chloride, and calcium gluconate) using only calcium diluted in D₅W, administered slowly with a volumetric infusion pump, to prevent adverse effects. Electrolyte Management • Monitor patient’s response to prescribed electrolyte therapy to evaluate effectiveness of therapy. • Consult physician if signs and symptoms of fluid and/or electrolyte imbalance persist or worsen so that corrective therapy can be initiated.

Outcomes (NOC)

Interventions (NIC) and Rationales

Electrolyte and Acid-Base Balance

• Serum calcium _____

• Serum magnesium _____

• Serum potassium _____

• Serum pH _____

• Serum glucose _____

• Sensation in extremities _____

Measurement Scale

1 = Severe deviation from normal range

2 = Substantial deviation from normal range

3 = Moderate deviation from normal range

4 = Mild deviation from normal range

5 = No deviation from normal range

• Muscle cramps _____

• Paresthesias _____

• Impaired cognition _____

Electrolyte Management: Hypocalcemia

• Monitor for clinical manifestations of hypocalcemia (e.g., tetany [classic sign]; tingling in tips of fingers, feet, or mouth; spasms of muscles in face or extremities; Trousseau’s sign; Chvostek’s sign; altered deep tendon reflexes; seizures [late sign]) to provide appropriate intervention.

• Monitor for central nervous system (CNS) manifestations of hypocalcemia (e.g., personality disturbances, anxiety, irritability, depression, and psychosis).

• Monitor for electrolyte imbalances associated with hypocalcemia (e.g., hyperphosphatemia, hypomagnesemia), and alkalosis to provide appropriate intervention.

• Administer appropriate prescribed calcium salt (e.g., calcium carbonate, calcium chloride, and calcium gluconate) using only calcium diluted in D₅W, administered slowly with a volumetric infusion pump, to prevent adverse effects.

Electrolyte Management

• Monitor patient’s response to prescribed electrolyte therapy to evaluate effectiveness of therapy.

• Consult physician if signs and symptoms of fluid and/or electrolyte imbalance persist or worsen so that corrective therapy can be initiated.

Nursing Diagnosis

Acute pain related to distention of pancreas, peritoneal irritation, obstruction of biliary tract, and ineffective pain and comfort measures as evidenced by communication of pain descriptors, guarding behavior, behaviors indicative of pain (e.g., moaning), diaphoresis, changes in blood pressure, pulse, and respiratory rate

Patient Goals

1. Reports adequate pain control

2. Uses nondrug techniques of pain management to reduce need for pain medication

Outcomes (NOC)	Interventions (NIC) and Rationales
Pain Control • Uses analgesics as recommended _____ • Uses nonanalgesic relief measures _____ • Reports changes in pain symptoms to health professional _____ • Reports uncontrolled symptoms to health professional _____ • Reports pain is controlled _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Introduction Nursing Management: Sexually Transmitted Infections Nursing Management: Integumentary Problems Nursing Management: Musculoskeletal Problems Stay updated, free articles. Join our Telegram channel Tags: Medical-Surgical Nursing Assessment and Management of Clinical P Nov 17, 2016 \| Posted by admin in NURSING \| Comments Off on Nursing Management: Liver, Pancreas, and Biliary Tract Problems Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access

Outcomes (NOC)

Interventions (NIC) and Rationales

Pain Control

• Uses analgesics as recommended _____

• Uses nonanalgesic relief measures _____

• Reports changes in pain symptoms to health professional _____

• Reports uncontrolled symptoms to health professional _____

• Reports pain is controlled _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated