10 Congestive Heart Failure Nursing Care Plans

January 24, 2012, 9:32 am

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Heart failure (HF) or Congestive Heart Failure (CHF) is a physiologic state in which he heart cannot pump enough blood to meet the metabolic needs of the body. Heart failure results from changes in systolic or diastolic function of the left ventricle. The heart fails when, because of intrinsic disease or structural it cannot handle a normal blood volume or, in absence of disease, cannot tolerate a sudden expansion in blood volume. Heart failure is not a disease itself; instead, the term refers to a clinical syndrome characterized by manifestations of volume overload, inadequate tissue perfusion, and poor exercise tolerance. Whatever the cause, pump failure results in hypoperfusion of tissues, followed by pulmonary and systemic venous congestion.

Because heart failure causes vascular congestion, it is often called congestive heart failure, although most cardiac specialist no longer use this term. Other terms used to denote heart failure include chronic heart failure, cardiac decompensation, cardiac insufficiency and ventricular failure (Joyce M. Black, 2008).

Here are 10 Congestive Heart Failure Nursing Care Plans

1. Decreased Cardiac Output - Congestive Heart Failure Nursing Care Plans

The heart fails to pump enough blood to meet the metabolic needs of the body. The blood flow that supplies the heart is also decreased thus decrease in cardiac output occurs, blood then is insufficient and making it difficult to circulate the blood to all parts of the body thus may cause altered heart rate and rhythm, weakness and paleness

NDx: Decreased cardiac output r/t altered heart rate and rhythm AEB bradycardia

Assessment	Planning	Nursing Interventions	Rationale	Evaluation
Subjective:(none)  Objectives: The patient manifested the following: with pale conjunctiva, nail beds and buccal mucosa irregular rhythm of pulse bradycardic pulse rate of 34 beats/min generalized weakness	Short Term:After 3-4 hours of nursing interventions, the patient will participate in activities that reduce the workload of the heart. Long Term: After 2-3 days of nursing interventions, the patient will be able to display hemodynamic stability.	Assess for abnormal heart and lung sounds. Monitor blood pressure and pulse Assess mental status and level of consciousness. Assess patient’s skin temperature and peripheral pulses. Monitor results of laboratory and diagnostic tests. Monitor oxygen saturation and ABGs. Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs. Implement strategies to treat fluid and electrolyte imbalances. Administer cardiac glycoside agents, as ordered, for signs of left sided failure, and monitor for toxicity. Encourage periods of rest and assist with all activities. Assist the patient in assuming a high Fowler’s position. Teach patient the pathophysiology of disease, medications Reposition patient every 2 hours Instruct patient to get adequate bed rest and sleep Instruct the SO not to leave the client unattended Allows detection of left-sided heart failure that may occur with chronic renal failure patients due to fluid volume excess as the diseased kidneys are unable to excrete water.	Patients with renal failure are most often hypertensive, which is attributable to excess fluid and the initiation of the rennin-angiotensin mechanism. The accumulation of waste products in the bloodstream impairs oxygen transport and intake by cerebral tissues, which may manifest itself as confusion, lethargy, and altered consciousness. Decreased perfusion and oxygenation of tissues secondary to anemia and pump ineffectiveness may lead to decreased in temperature and peripheral pulses that are diminished and difficult to palpate. Results of the test provide clues to the status of the disease and response to treatments. Provides information regarding the heart’s ability to perfuse distal tissues with oxygenated blood Makes more oxygen available for gas exchange, assisting to alleviate signs of hypoxia and subsequent activity intolerance. Decreases the risk for development of cardiac output due to imbalances. Digitalis has a positive isotropic effect on the myocardium that strengthens contractility, thus improving cardiac output. Reduces cardiac workload and minimizes myocardial oxygen consumption. Allows for better chest expansion, thereby improving pulmonary capacity. Provides the patient with needed information for management of disease and for compliance. To prevent occurrence of bed sores To promote relaxation to the body To ensure safety and reduce risk for falls that may lead to injury	Short Term:After nursing interventions, the patient shall have participated in activities that reduce the workload of the heart. Long Term: After 2-3 days of nursing interventions, the patient shall have been able to display hemodynamic stability.

 

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Imbalanced Nutrition — Liver Cirrhosis Nursing Care Plan (NCP)

May 1, 2012, 8:11 am

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Nursing Diagnosis: Nutrition: imbalanced, less than body requirements

May be related to

• Inadequate diet; inability to process/digest nutrients
• Anorexia, nausea/vomiting, indigestion, early satiety (ascites)
• Abnormal bowel function

Possibly evidenced by

• Weight loss
• Changes in bowel sounds and function
• Poor muscle tone/wasting
• Imbalances in nutritional studies

Desired Outcomes

• Demonstrate progressive weight gain toward goal with patient-appropriate normalization of laboratory values.
• Experience no further signs of malnutrition.

8 Liver Cirrhosis Nursing Care Plan (NCP)

1. Imbalanced Nutrition — Liver Cirrhosis Nursing Care Plan (NCP)
2. Excess Fluid Volume — Liver Cirrhosis Nursing Care Plan (NCP)
3. Impaired Skin Integrity — Liver Cirrhosis Nursing Care Plan (NCP)
4. Ineffective Breathing Pattern — Liver Cirrhosis Nursing Care Plan (NCP)
5. Risk for Injury — Liver Cirrhosis Nursing Care Plan (NCP)
6. Risk for Acute Confusion — Liver Cirrhosis Nursing Care Plan (NCP)
7. Disturbed Body Image/Self-Esteem — Liver Cirrhosis Nursing Care Plan (NCP)
8. Knowledge Deficit — Liver Cirrhosis Nursing Care Plan (NCP)

Imbalanced Nutrition — Liver Cirrhosis Nursing Care Plan (NCP): Nursing Interventions & Rationale

Nursing Interventions	Rationale
Measure dietary intake by calorie count.	Provides information about intake, needs/deficiencies.
Weigh as indicated. Compare changes in fluid status, recent weight history, skinfold measurements.	It may be difficult to use weight as a direct indicator of nutritional status in view of edema/ascites. Skinfold measurements are useful in assessing changes in muscle mass and subcutaneous fat reserves.
Assist/encourage patient to eat; explain reasons for the types of diet. Feed patient if tiring easily, or have SO assist patient. Consider preferences in food choices.	Improved nutrition/diet is vital to recovery. Patient may eat better if family is involved and preferred foods are included as much as possible.
Encourage patient to eat all meals/supplementary feedings.	Patient may pick at food or eat only a few bites because of loss of interest in food or because of nausea, generalized weakness, malaise.
Recommend/provide small, frequent meals.	Poor tolerance to larger meals may be due to increased intra-abdominal pressure/ascites.
Provide salt substitutes, if allowed; avoid those containing ammonium.	Salt substitutes enhance the flavor of food and aid in increasing appetite; ammonia potentiates risk of encephalopathy.
Restrict intake of caffeine, gas-producing or spicy and excessively hot or cold foods.	Aids in reducing gastric irritation/diarrhea and abdominal discomfort that may impair oral intake/digestion.
Suggest soft foods, avoiding roughage if indicated.	Hemorrhage from esophageal varices may occur in advanced cirrhosis.
Encourage frequent mouth care, especially before meals.	Patient is prone to sore and/or bleeding gums and bad taste in mouth, which contributes to anorexia.
Promote undisturbed rest periods, especially before meals.	Conserving energy reduces metabolic demands on the liver and promotes cellular regeneration.
Recommend cessation of smoking.	Reduces excessive gastric stimulation and risk of irritation/bleeding.
Monitor laboratory studies, e.g., serum glucose, prealbumin/albumin, total protein, ammonia.	Glucose may be decreased because of impaired glycogenesis, depleted glycogen stores, or inadequate intake. Protein may be low because of impaired metabolism, decreased hepatic synthesis, or loss into peritoneal cavity (ascites). Elevation of ammonia level may require restriction of protein intake to prevent serious complications.
Maintain NPO status when indicated.	Initially, GI rest may be required in acutely ill patients to reduce demands on the liver and production of ammonia/urea in the GI tract.
Consult with dietitian to provide diet that is high in calories and simple carbohydrates, low in fat, and moderate to high in protein; limit sodium and fluid as necessary. Provide liquid supplements as indicated.	High-calorie foods are desired inasmuch as patient intake is usually limited. Carbohydrates supply readily available energy. Fats are poorly absorbed because of liver dysfunction and may contribute to abdominal discomfort. Proteins are needed to improve serum protein levels to reduce edema and to promote liver cell regeneration.Note: Protein and foods high in ammonia (e.g., gelatin) are restricted if ammonia level is elevated or if patient has clinical signs of hepatic encephalopathy. In addition, these individuals may tolerate vegetable protein better than meat protein.
Provide tube feedings, TPN, lipids if indicated.	May be required to supplement diet or to provide nutrients when patient is too nauseated or anorexic to eat or when esophageal varices interfere with oral intake.

Excess Fluid Volume — Liver Cirrhosis Nursing Care Plan (NCP)

May 1, 2012, 8:15 am

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NURSING DIAGNOSIS: Fluid Volume excess

May be related to

• Compromised regulatory mechanism (e.g., syndrome of inappropriate antidiuretic hormone [SIADH], decreased plasma proteins, malnutrition)
• Excess sodium/fluid intake

Possibly evidenced by

• Edema, anasarca, weight gain
• Intake greater than output, oliguria, changes in urine specific gravity
• Dyspnea, adventitious breath sounds, pleural effusion
• BP changes, altered CVP
• JVD, positive hepatojugular reflex
• Altered electrolyte levels
• Change in mental status

Desired Outcomes

• Demonstrate stabilized fluid volume, with balanced I&O, stable weight, vital signs within patient’s normal range, and absence of edema.

8 Liver Cirrhosis Nursing Care Plan (NCP)

1. Imbalanced Nutrition — Liver Cirrhosis Nursing Care Plan (NCP)
2. Excess Fluid Volume — Liver Cirrhosis Nursing Care Plan (NCP)
3. Impaired Skin Integrity — Liver Cirrhosis Nursing Care Plan (NCP)
4. Ineffective Breathing Pattern — Liver Cirrhosis Nursing Care Plan (NCP)
5. Risk for Injury — Liver Cirrhosis Nursing Care Plan (NCP)
6. Risk for Acute Confusion — Liver Cirrhosis Nursing Care Plan (NCP)
7. Disturbed Body Image/Self-Esteem — Liver Cirrhosis Nursing Care Plan (NCP)
8. Knowledge Deficit — Liver Cirrhosis Nursing Care Plan (NCP)

Excess Fluid Volume — Liver Cirrhosis Nursing Care Plan (NCP): Nursing Interventions & Rationale

Nursing Interventions	Rationale
Measure I&O, noting positive balance (intake in excess of output). Weigh daily, and note gain more than 0.5 kg/day.	Reflects circulating volume status, developing/resolution of fluid shifts, and response to therapy. Positive balance/weight gain often reflects continuing fluid retention. Note: Decreased circulating volume (fluid shifts) may directly affect renal function/urine output, resulting in hepatorenal syndrome.
Monitor BP (and CVP if available). Note JVD/abdominal vein distension.	BP elevations are usually associated with fluid volume excess but may not occur because of fluid shifts out of the vascular space. Distension of external jugular and abdominal veins is associated with vascular congestion.
Assess respiratory status, noting increased respiratory rate, dyspnea.	Indicative of pulmonary congestion/edema.
Auscultate lungs, noting diminished/absent breath sounds and developing adventitious sounds (e.g., crackles).	Increasing pulmonary congestion may result in consolidation, impaired gas exchange, and complications, e.g., pulmonary edema.
Monitor for cardiac dysrhythmias. Auscultate heart sounds, noting development of S3/S4 gallop rhythm.	May be caused by HF, decreased coronary arterial perfusion, and electrolyte imbalance.
Assess degree of peripheral/dependent edema.	Fluids shift into tissues as a result of sodium and water retention, decreased albumin, and increased antidiuretic hormone (ADH).
Measure abdominal girth.	Reflects accumulation of fluid (ascites) resulting from loss of plasma proteins/fluid into peritoneal space. Note:Excessive fluid accumulation can reduce circulating volume, creating a deficit (signs of dehydration).
Encourage bedrest when ascites is present.	May promote recumbency-induced diuresis.
Provide frequent mouth care; occasional ice chips (if NPO).	Decreases sensation of thirst.
Monitor serum albumin and electrolytes (particularly potassium and sodium).	Decreased serum albumin affects plasma colloid osmotic pressure, resulting in edema formation. Reduced renal blood flow accompanied by elevated ADH and aldosterone levels and the use of diuretics (to reduce total body water) may cause various electrolyte shifts/imbalances.
Monitor serial chest x-rays.	Vascular congestion, pulmonary edema, and pleural effusions frequently occur.
Restrict sodium and fluids as indicated.	Sodium may be restricted to minimize fluid retention in extravascular spaces. Fluid restriction may be necessary to correct/prevent dilutional hyponatremia.
Administer salt-free albumin/plasma expanders as indicated.	Albumin may be used to increase the colloid osmotic pressure in the vascular compartment (pulling fluid into vascular space), thereby increasing effective circulating volume and decreasing formation of ascites.
Administer medications as indicated:Diuretics, e.g., spironolactone (Aldactone), furosemide (Lasix);       Potassium;     Positive inotropic drugs and arterial vasodilators.	Used with caution to control edema and ascites, block effect of aldosterone, and increase water excretion while sparing potassium when conservative therapy with bedrest and sodium restriction does not alleviate problem.  Serum and cellular potassium are usually depleted because of liver disease and urinary losses.   Given to increase cardiac output/improve renal blood flow and function, thereby reducing excess fluid.

Impaired Skin Integrity — Liver Cirrhosis Nursing Care Plan (NCP)

May 1, 2012, 8:18 am

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NURSING DIAGNOSIS: Skin Integrity, risk for impaired

Risk factors may include

• Altered circulation/metabolic state
• Accumulation of bile salts in skin
• Poor skin turgor, skeletal prominence, presence of edema, ascites

Desired Outcomes

• Maintain skin integrity.
• Identify individual risk factors and demonstrate behaviors/techniques to prevent skin breakdown.

8 Liver Cirrhosis Nursing Care Plan (NCP)

1. Imbalanced Nutrition — Liver Cirrhosis Nursing Care Plan (NCP)
2. Excess Fluid Volume — Liver Cirrhosis Nursing Care Plan (NCP)
3. Impaired Skin Integrity — Liver Cirrhosis Nursing Care Plan (NCP)
4. Ineffective Breathing Pattern — Liver Cirrhosis Nursing Care Plan (NCP)
5. Risk for Injury — Liver Cirrhosis Nursing Care Plan (NCP)
6. Risk for Acute Confusion — Liver Cirrhosis Nursing Care Plan (NCP)
7. Disturbed Body Image/Self-Esteem — Liver Cirrhosis Nursing Care Plan (NCP)
8. Knowledge Deficit — Liver Cirrhosis Nursing Care Plan (NCP)

Impaired Skin Integrity — Liver Cirrhosis Nursing Care Plan (NCP): Nursing Interventions & Rationale

Nursing Interventions	Rationale
Inspect skin surfaces/pressure points routinely. Gently massage bony prominences or areas of continued stress. Use emollient lotions; limit use of soap for bathing.	Edematous tissues are more prone to breakdown and to the formation of decubitus. Ascites may stretch the skin to the point of tearing in severe cirrhosis.
Encourage/assist with repositioning on a regular schedule, while in bed/chair, and active/passive ROM exercises as appropriate.	Repositioning reduces pressure on edematous tissues to improve circulation. Exercises enhance circulation and improve/maintain joint mobility.
Recommend elevating lower extremities.	Enhances venous return and reduces edema formation in extremities.
Keep linens dry and free of winkles.	Moisture aggravates pruritus and increases risk of skin breakdown.
Suggest clipping fingernails short; provide mittens/gloves if indicated.	Prevents patient from inadvertently injuring the skin, especially while sleeping.
Encourage/provide perineal care following urination and bowel movement.	Prevents skin excoriation breakdown from bile salts.
Use alternating pressure mattress, egg-crate mattress, waterbed, sheepskins, as indicated.	Reduces dermal pressure, increases circulation, and diminishes risk of tissue ischemia/breakdown.
Apply calamine lotion, provide baking soda baths. Administer medications such as cholestyramine (Questran), hydroxyzine (Atarax), diphenhydramine (Benadryl), ifindicated.	May be soothing/provide relief of itching associated with jaundice, bile salts in skin.

Ineffective Breathing Pattern — Liver Cirrhosis Nursing Care Plan (NCP)

May 1, 2012, 8:22 am

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NURSING DIAGNOSIS: Breathing Pattern, risk for ineffective

Risk factors may include

• Intra-abdominal fluid collection (ascites)
• Decreased lung expansion, accumulated secretions
• Decreased energy, fatigue

Desired Outcomes

• Maintain effective respiratory pattern; be free of dyspnea and cyanosis, with ABGs and vital capacity within acceptable range.

8 Liver Cirrhosis Nursing Care Plan (NCP)

1. Imbalanced Nutrition — Liver Cirrhosis Nursing Care Plan (NCP)
2. Excess Fluid Volume — Liver Cirrhosis Nursing Care Plan (NCP)
3. Impaired Skin Integrity — Liver Cirrhosis Nursing Care Plan (NCP)
4. Ineffective Breathing Pattern — Liver Cirrhosis Nursing Care Plan (NCP)
5. Risk for Injury — Liver Cirrhosis Nursing Care Plan (NCP)
6. Risk for Acute Confusion — Liver Cirrhosis Nursing Care Plan (NCP)
7. Disturbed Body Image/Self-Esteem — Liver Cirrhosis Nursing Care Plan (NCP)
8. Knowledge Deficit — Liver Cirrhosis Nursing Care Plan (NCP)

Ineffective Breathing Pattern — Liver Cirrhosis Nursing Care Plan (NCP): Nursing Interventions & Rationale

Nursing Interventions	Rationale
Monitor respiratory rate, depth, and effort.	Rapid shallow respirations/dyspnea may be present because of hypoxia and/or fluid accumulation in abdomen.
Auscultate breath sounds, noting crackles, wheezes, rhonchi.	Indicates developing complications (e.g., presence of adventitious sounds reflects accumulation of fluid/secretions; absent/diminished sounds suggest atelectasis), increasing risk of infection.
Investigate changes in level of consciousness.	Changes in mentation may reflect hypoxemia and respiratory failure, which often accompany hepatic coma.
Keep head of bed elevated. Position on sides.	Facilitates breathing by reducing pressure on the diaphragm, and minimizes risk of aspiration of secretions.
Encourage frequent repositioning and deep-breathing exercises/coughing as appropriate.	Aids in lung expansion and mobilizing secretions.
Monitor temperature. Note presence of chills, increased coughing, changes in color/character of sputum.	Indicative of onset of infection, e.g., pneumonia.
Monitor serial ABGs, pulse oximetry, vital capacity measurements, chest x-rays.	Reveals changes in respiratory status, developing pulmonary complications.
Provide supplemental O2 as indicated.	May be necessary to treat/prevent hypoxia. If respirations/oxygenation inadequate, mechanical ventilation may be required.
Demonstrate/assist with respiratory adjuncts, e.g., incentive spirometer.	Reduces incidence of atelectasis, enhances mobilization of secretions.
Prepare for/assist with acute care procedures, e.g.:Paracentesis;     Peritoneovenous shunt.	Occasionally done to remove ascites fluid to relieve abdominal pressure when respiratory embarrassment is not corrected by other measures.Surgical implant of a catheter to return accumulated fluid in the abdominal cavity to systemic circulation via the vena cava; provides long-term relief of ascites and improvement in respiratory function.

Disturbed Body Image/Self-Esteem — Liver Cirrhosis Nursing Care Plan (NCP)

May 1, 2012, 8:37 am

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NURSING DIAGNOSIS: Self-Esteem/Body Image disturbed

May be related to

• Biophysical changes/altered physical appearance
• Uncertainty of prognosis, changes in role function
• Personal vulnerability
• Self-destructive behavior (alcohol-induced disease)

Possibly evidenced by

• Verbalization of change/restriction in lifestyle
• Fear of rejection or reaction by others
• Negative feelings about body/abilities
• Feelings of helplessness, hopelessness, or powerlessness

Desired Outcomes

• Verbalize understanding of changes and acceptance of self in the present situation.
• Identify feelings and methods for coping with negative perception of self.

8 Liver Cirrhosis Nursing Care Plan (NCP)

1. Imbalanced Nutrition — Liver Cirrhosis Nursing Care Plan (NCP)
2. Excess Fluid Volume — Liver Cirrhosis Nursing Care Plan (NCP)
3. Impaired Skin Integrity — Liver Cirrhosis Nursing Care Plan (NCP)
4. Ineffective Breathing Pattern — Liver Cirrhosis Nursing Care Plan (NCP)
5. Risk for Injury — Liver Cirrhosis Nursing Care Plan (NCP)
6. Risk for Acute Confusion — Liver Cirrhosis Nursing Care Plan (NCP)
7. Disturbed Body Image/Self-Esteem — Liver Cirrhosis Nursing Care Plan (NCP)
8. Knowledge Deficit — Liver Cirrhosis Nursing Care Plan (NCP)

Disturbed Body Image/Self-Esteem — Liver Cirrhosis Nursing Care Plan (NCP): Nursing Interventions & Rationale

Nursing Interventions	Rationale
Discuss situation/encourage verbalization of fears and concerns. Explain relationship between nature of disease and symptoms.	Patient is very sensitive to body changes and may also experience feelings of guilt when cause is related to alcohol (70%) or other drug use.
Support and encourage patient; provide care with a positive, friendly attitude.	Caregivers sometimes allow judgmental feelings to affect the care of patient and need to make every effort to help patient feel valued as a person.
Encourage family/SO to verbalize feelings, visit freely/participate in care.	Family members may feel guilty about patient’s condition and may be fearful of impending death. They need nonjudgmental emotional support and free access to patient. Participation in care helps them feel useful and promotes trust between staff, patient, and SO.
Assist patient/SO to cope with change in appearance; suggest clothing that does not emphasize altered appearance, e.g., use of red, blue, or black clothing.	Patient may present unattractive appearance as a result of jaundice, ascites, ecchymotic areas. Providing support can enhance self-esteem and promote patient sense of control.
Refer to support services, e.g., counselors, psychiatric resources, social service, clergy, and/or alcohol treatment program.	Increased vulnerability/concerns associated with this illness may require services of additional professional resources.

Knowledge Deficit — Liver Cirrhosis Nursing Care Plan (NCP)

May 1, 2012, 8:43 am

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NURSING DIAGNOSIS: Knowledge Deficit

May be related to

• Lack of exposure/recall; information misinterpretation
• Unfamiliarity with information resources

Possibly evidenced by

• Questions; request for information, statement of misconception
• Inaccurate follow-through of instructions/development of preventable complications

Desired Outcomes

• Verbalize understanding of disease process/prognosis, potential complications.
• Correlate symptoms with causative factors.
• Identify/initiate necessary lifestyle changes and participate in care.

8 Liver Cirrhosis Nursing Care Plan (NCP)

1. Imbalanced Nutrition — Liver Cirrhosis Nursing Care Plan (NCP)
2. Excess Fluid Volume — Liver Cirrhosis Nursing Care Plan (NCP)
3. Impaired Skin Integrity — Liver Cirrhosis Nursing Care Plan (NCP)
4. Ineffective Breathing Pattern — Liver Cirrhosis Nursing Care Plan (NCP)
5. Risk for Injury — Liver Cirrhosis Nursing Care Plan (NCP)
6. Risk for Acute Confusion — Liver Cirrhosis Nursing Care Plan (NCP)
7. Disturbed Body Image/Self-Esteem — Liver Cirrhosis Nursing Care Plan (NCP)
8. Knowledge Deficit — Liver Cirrhosis Nursing Care Plan (NCP)

Knowledge Deficit — Liver Cirrhosis Nursing Care Plan (NCP): Nursing Interventions & Rationale

Nursing Interventions	Rationale
Review disease process/prognosis and future expectations.	Provides knowledge base from which patient can make informed choices.
Stress importance of avoiding alcohol. Give information about community services available to aid in alcohol rehabilitation if indicated.	Alcohol is the leading cause in the development of cirrhosis.
Inform patient of altered effects of medications with cirrhosis and the importance of using only drugs prescribed or cleared by a healthcare provider who is familiar with patient’s history.	Some drugs are hepatotoxic (especially narcotics, sedatives, and hypnotics). In addition, the damaged liver has a decreased ability to metabolize all drugs, potentiating cumulative effect and/or aggravation of bleeding tendencies.
Review procedure for maintaining function of peritoneovenous shunt when present.	Insertion of a Denver shunt requires patient to periodically pump the chamber to maintain patency of the device. Patients with a LeVeen shunt may wear an abdominal binder and/or engage in a Valsalva maneuver to maintain shunt function.
Assist patient identifying support person(s).	Because of length of recovery, potential for relapses, and slow convalescence, support systems are extremely important in maintaining behavior modifications.
Emphasize the importance of good nutrition. Recommend avoidance of high-protein/salty foods, onions, and strong cheeses. Provide written dietary instructions.	Proper dietary maintenance and avoidance of foods high in sodium and protein aid in remission of symptoms and help prevent ammonia buildup and further liver damage. Written instructions are helpful for patient to refer to at home.
Stress necessity of follow-up care and adherence to therapeutic regimen.	Chronic nature of disease has potential for life-threatening complications. Provides opportunity for evaluation of effectiveness of regimen, including patency of shunt if used.
Discuss sodium and salt substitute restrictions and necessity of reading labels on food and OTC drugs.	Minimizes ascites and edema formation. Overuse of substitutes may result in other electrolyte imbalances. Food, OTC/personal care products (e.g., antacids, some mouthwashes) may contain sodium or alcohol.
Encourage scheduling activities with adequate rest periods.	Adequate rest decreases metabolic demands on the body and increases energy available for tissue regeneration.
Promote diversional activities that are enjoyable to patient.	Prevents boredom and minimizes anxiety and depression.
Recommend avoidance of persons with infections, especially URI.	Decreased resistance, altered nutritional status, and immune response (e.g., leukopenia may occur with splenomegaly) potentiate risk of infection.
Identify environmental dangers, e.g., carbon tetrachloride–type cleaning agents, exposure to hepatitis.	Can precipitate recurrence.
Instruct patient/SO of signs/symptoms that warrant notification of healthcare provider, e.g., increased abdominal girth; rapid weight loss/gain; increased peripheral edema; increased dyspnea, fever; blood in stool or urine; excess bleeding of any kind; jaundice.	Prompt reporting of symptoms reduces risk of further hepatic damage and provides opportunity to treat complications before they become life-threatening.
Instruct SO to notify healthcare providers of any confusion, untidiness, night wandering, tremors, or personality change.	Changes (reflecting deterioration) may be more apparent to SO, although insidious changes may be noted by others with less frequent contact with patient.

Nursing Care Plan – 8 Liver Cirrhosis Nursing Care Plan (NCP)

May 1, 2012, 8:49 am

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Cirrhosis is a chronic disease of the liver characterized by alteration in structure, degenerative changes and widespread destruction of hepatic cells, impairing cellular function and impeding blood flow through the liver. Causes include malnutrition, inflammation (bacterial or viral), and poisons (e.g., alcohol, carbon tetrachloride, acetaminophen). Cirrhosis is the fourth leading cause of death in the United States among people ages 35 to 55 and represents a serious threat to long-term health.

Below are 8 Nursing Care Plan (NCP) for liver cirrhosis.

8 Liver Cirrhosis Nursing Care Plan (NCP)

1. Imbalanced Nutrition — Liver Cirrhosis Nursing Care Plan (NCP)
2. Excess Fluid Volume — Liver Cirrhosis Nursing Care Plan (NCP)
3. Impaired Skin Integrity — Liver Cirrhosis Nursing Care Plan (NCP)
4. Ineffective Breathing Pattern — Liver Cirrhosis Nursing Care Plan (NCP)
5. Risk for Injury — Liver Cirrhosis Nursing Care Plan (NCP)
6. Risk for Acute Confusion — Liver Cirrhosis Nursing Care Plan (NCP)
7. Disturbed Body Image/Self-Esteem — Liver Cirrhosis Nursing Care Plan (NCP)
8. Knowledge Deficit — Liver Cirrhosis Nursing Care Plan (NCP)

Nursing Priorities

1. Maintain adequate nutrition.
2. Prevent complications.
3. Enhance self-concept, acceptance of situation.
4. Provide information about disease process/prognosis, potential complications, and treatment needs.

Discharge Goals

1. Nutritional intake adequate for individual needs.
2. Complications prevented/minimized.
3. Dealing effectively with current reality.
4. Disease process, prognosis, potential complications, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.

Other Nursing Diagnoses

• Fatigue—decreased metabolic energy production, states of discomfort, altered body chemistry (e.g., changes in liver function, effect on target organs, alcohol withdrawal).
• Nutrition: imbalanced, less than body requirements—inadequate diet; inability to process/digest nutrients; anorexia, nausea/vomiting, indigestion, early satiety (ascites); abnormal bowel function.
• Therapeutic Regimen: risk for ineffective management—perceived benefit, social support deficit, economic difficulties.
• Family Processes, dysfunctional: alcoholism—abuse of alcohol, resistance to treatment, inadequate coping/lack of problem-solving skills, addictive personality/codependency.
• Caregiver Role Strain, risk for—addiction or codependency, family dysfunction before caregiving situation, presence of situational stressors, such as economic vulnerability, hospitalization, changes in employment.

Diagnostic Studies

• Liver scans/biopsy: Detects fatty infiltrates, fibrosis, destruction of hepatic tissues, tumors (primary or metastatic), associated ascites.
• Percutaneous transhepatic cholangiography (PTHC): May be done to rule out/differentiate causes of jaundice or to perform liver biopsy.
• Esophagogastroduodenoscopy (EGD): May demonstrate presence of esophageal varices, stomach irritation or ulceration, duodenal ulceration or bleeding.
• Percutaneous transhepatic portal angiography (PTPA): Visualizes portal venous system circulation.
• Serum bilirubin: Elevated because of cellular disruption, inability of liver to conjugate, or biliary obstruction.
• Liver enzymes:
• AST/ALT, LDH, and isoenzymes (LDH₅): Increased because of cellular damage and release of enzymes.
• Alkaline phosphatase (ALP) and isoenzyme (LAP1): Elevated because of reduced excretion.
• Gamma glutamyl transpeptidase (GTT): Elevated.
• Serum albumin: Decreased because of depressed synthesis.
• Globulins (IgA and IgG): Increased synthesis.
• CBC: Hb/Hct and RBCs may be decreased because of bleeding. RBC destruction and anemia is seen with hypersplenism and iron deficiency. Leukopenia may be present as a result of hypersplenism.
• PT/activated partial thromboplastin time (aPTT): Prolonged (decreased synthesis of prothrombin)
• Fibrinogen: Decreased.
• BUN: Elevation indicates breakdown of blood/protein.
• Serum ammonia: Elevated because of inability to convert ammonia to urea.
• Serum glucose: Hypoglycemia suggests impaired glycogenesis.
• Electrolytes: Hypokalemia may reflect increased aldosterone, although various imbalances may occur. Hypocalcemia may occur because of impaired absorption of vitamin D.
• Nutrient studies: Deficiency of vitamins A, B₁₂, C, K; folic acid, and iron may be noted.
• Urine urobilinogen: May/may not be present. Serves as guide for differentiating liver disease, hemolytic disease, and biliary obstruction.
• Fecal urobilinogen: Decreased.

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Deficient Fluid Volume — Hepatitis Nursing Care Plan (NCP)

June 10, 2012, 6:07 am

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NURSING DIAGNOSIS: Fluid Volume, risk for deficient

Risk factors may include

• Excessive losses through vomiting and diarrhea, third-space shift
• Altered clotting process

Possibly evidenced by

• [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes

Hydration (NOC)

• Maintain adequate hydration, as evidenced by stable vital signs, good skin turgor, capillary refill, strong peripheral pulses, and individually appropriate urinary output.

Coagulation Status (NOC)

• Be free of signs of hemorrhage with clotting times WNL.

7 Hepatitis Nursing Care Plan (NCP)

1. Imbalanced Nutrition — Hepatitis Nursing Care Plan (NCP)
2. Deficient Fluid Volume — Hepatitis Nursing Care Plan (NCP)
3. Low Self-Esteem — Hepatitis Nursing Care Plan (NCP)
4. Risk for Infection — Hepatitis Nursing Care Plan (NCP)
5. Fatigue — Hepatitis Nursing Care Plan (NCP)
6. Impaired Skin Integrity — Hepatitis Nursing Care Plan (NCP)
7. Knowledge Deficit — Hepatitis Nursing Care Plan (NCP)

Deficient Fluid Volume — Hepatitis Nursing Care Plan (NCP): Nursing Interventions & Rationale

Nursing Interventions	Rationale
Monitor I&O, compare with periodic weight. Note enteric losses, e.g., vomiting and diarrhea.	Provides information about replacement needs/effects of therapy. Note: Diarrhea may be due to transient flulike response to viral infection or may represent a more serious problem of obstructed portal blood flow with vascular congestion in the GI tract, or it may be the intended result of medication use (neomycin, lactulose) to decrease serum ammonia levels in the presence of hepatic encephalopathy.
Assess vital signs, peripheral pulses, capillary refill, skin turgor, and mucous membranes.	Indicators of circulating volume/perfusion.
Check for ascites for edema formation. Measure abdominal girth as indicated.	Useful in monitoring progression/resolution of fluid shifts (edema/ascites).
Use small-gauge needles for injections, applying pressure for longer than usual after venipuncture.	Reduces possibility of bleeding into tissues.
Have patient use cotton/sponge swabs and mouthwash instead of toothbrush.	Avoids trauma and bleeding of the gums.
Observe for signs of bleeding, e.g., hematuria/melena, ecchymosis, oozing from gums/puncture sites	Prothrombin levels are reduced and coagulation times prolonged when vitamin K absorption is altered in GI tract and synthesis of prothrombin is decreased in affected liver.
Monitor periodic laboratory values, e.g., Hb/Hct, Na, albumin, and clothing times.	Reflects hydration and identifies sodium retention/protein deficits, which may lead to edema formation. Deficits in clotting potentiate risk of bleeding/hemorrhage.
Administer antidiarrheal agents, e.g., diphenoxylate with atropine (Lomotil).	Reduces fluid/electrolyte loss from GI tract.
Provide IV fluids (usually glucose), electrolytes.  Protein hydrolysates.	Provides fluid and electrolyte replacement in acute toxic state.
Administer medications as indicated, e.g.:Vitamin K;      Antacids or H2-receptor antagonists, e.g., cimetidine (Tagamet).   Infuse fresh frozen plasma, as indicated.	Correction of albumin/protein deficits can aid in return of fluid from tissues to the circulatory system.Because absorption is altered, supplementation may prevent coagulation problems, which may occur if clotting factors/prothrombin time (PT) is depressed.  Neutralize/reduce gastric secretions to lower risk of gastric irritation/bleeding.   May be required to replace clotting factors in the presence of coagulation defects.

Excess Fluid Volume — Heart Failure (CHF) Nursing Care Plan (NCP)

June 12, 2012, 12:31 am

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NURSING DIAGNOSIS: Fluid Volume excess

May be related to

• Reduced glomerular filtration rate (decreased cardiac output)/increased antidiuretic hormone (ADH) production, and sodium/water retention

Possibly evidenced by

• Orthopnea, S₃ heart sound
• Oliguria, edema, JVD, positive hepatojugular reflex
• Weight gain
• Hypertension
• Respiratory distress, abnormal breath sounds

Desired Outcomes

Fluid Balance (NOC)

• Demonstrate stabilized fluid volume with balanced intake and output, breath sounds clear/clearing, vital signs within acceptable range, stable weight, and absence of edema.
• Verbalize understanding of individual dietary/fluid restrictions.

6 Heart Failure Nursing Care Plan (NCP)

1. Decreased Cardiac Output — Heart Failure (CHF) Nursing Care Plan (NCP)
2. Activity Intolerance — Heart Failure (CHF) Nursing Care Plan (NCP)
3. Excess Fluid Volume — Heart Failure (CHF) Nursing Care Plan (NCP)
4. Impaired Gas Exchange — Heart Failure (CHF) Nursing Care Plan (NCP)
5. Impaired Skin Integrity — Heart Failure (CHF) Nursing Care Plan (NCP)
6. Knowledge Deficit — Heart Failure (CHF) Nursing Care Plan (NCP)

Excess Fluid Volume — Heart Failure (CHF) Nursing Care Plan (NCP): Nursing Interventions & Rationale

Nursing Interventions	Rationale
Monitor urine output, noting amount and color, as well as time of day when diuresis occurs.	Urine output may be scanty and concentrated (especially during the day) because of reduced renal perfusion. Recumbency favors diuresis; therefore, urine output may be increased at night/during bedrest.
Monitor/calculate 24-hour intake and output (I&O) balance.	Diuretic therapy may result in sudden/excessive fluid loss (circulating hypovolemia), even though edema/ascites remains.
Maintain chair or bedrest in semi-Fowler’s position during acute phase.	Recumbency increases glomerular filtration and decreases production of ADH, thereby enhancing diuresis.
Establish fluid intake schedule if fluids are medically restricted, incorporating beverage preferences when possible. Give frequent mouth care/ice chips as part of fluid allotment.	Involving patient in therapy regimen may enhance sense of control and cooperation with restrictions.
Weigh daily.	Documents changes in/resolution of edema in response to therapy. A gain of 5 lb represents approximately 2 L of fluid. Conversely, diuretics can result in rapid/excessive fluid shifts and weight loss.
Assess for distended neck and peripheral vessels. Inspect dependent body areas for edema with/without pitting; note presence of generalized body edema (anasarca).	Excessive fluid retention may be manifested by venous engorgement and edema formation. Peripheral edema begins in feet/ankles (or dependent areas) and ascends as failure worsens. Pitting edema is generally obvious only after retention of at least 10 lb of fluid. Increased vascular congestion (associated with RHF) eventually results in systemic tissue edema.
Change position frequently. Elevate feet when sitting. Inspect skin surface, keep dry, and provide padding as indicated.	Edema formation, slowed circulation, altered nutritional intake, and prolonged immobility/bedrest are cumulative stressors that affect skin integrity and require close supervision/preventive interventions.
Auscultate breath sounds, noting decreased and/or adventitious sounds, e.g., crackles, wheezes. Note presence of increased dyspnea, tachypnea, orthopnea, paroxysmal nocturnal dyspnea, persistent cough.	Excess fluid volume often leads to pulmonary congestion. Symptoms of pulmonary edema may reflect acute left-sided HF. RHF’s respiratory symptoms (dyspnea, cough, orthopnea) may have slower onset but are more difficult to reverse.
Investigate reports of sudden extreme dyspnea/air hunger, need to sit straight up, sensation of suffocation, feelings of panic or impending doom.	May indicate development of complications (pulmonary edema/embolus) and differs from orthopnea paroxysmal nocturnal dyspnea in that it develops much more rapidly and requires immediate intervention.
Monitor BP and central venous pressure (CVP)	Hypertension and elevated CVP suggest fluid volume excess and may reflect developing/increasing pulmonary congestion, HF.
Assess bowel sounds. Note complaints of anorexia, nausea, abdominal distension, constipation.	Visceral congestion (occurring in progressive HF) can alter gastric/intestinal function.
Provide small, frequent, easily digestible meals.	Reduced gastric motility can adversely affect digestion and absorption. Small, frequent meals may enhance digestion/prevent abdominal discomfort.
Measure abdominal girth, as indicated.	In progressive RHF, fluid may shift into the peritoneal space, causing increasing abdominal girth (ascites).
Encourage verbalization of feelings regarding limitations.	Expression of feelings/concerns may decrease stress/anxiety, which is an energy drain that can contribute to feelings of fatigue.
Palpate abdomen. Note reports of right upper quadrant pain/tenderness.	Advancing HF leads to venous congestion, resulting in abdominal distension, liver engorgement (hepatomegaly), and pain. This can alter liver function and impair/prolong drug metabolism.
Administer medications as indicated:Diuretics, e.g., furosemide (Lasix), bumetanide (Bumex)   Thiazides with potassium-sparing agents, e.g., spironolactone (Aldactone)   Potassium supplements, e.g., K-Dur	Signs of potassium and sodium deficits that may occur because of fluid shifts and diuretic therapy.Increases rate of urine flow and may inhibit reabsorption of sodium/chloride in the renal tubules.  Promotes diuresis without excessive potassium losses.     Replaces potassium that is lost as a common side effect of diuretic therapy, which can adversely affect cardiac function.
Maintain fluid/sodium restrictions as indicated.	Reduces total body water/prevents fluid reaccumulation.
Consult with dietitian.	May be necessary to provide diet acceptable to patient that meets caloric needs within sodium restriction.
Monitor chest x-ray.	Reveals changes indicative of increase/resolution of pulmonary congestion.
Assist with rotating tourniquets/phlebotomy, dialysis, or ultrafiltration as indicated.	Although not frequently used, mechanical fluid removal rapidly reduces circulating volume, especially in pulmonary edema refractory to other therapies

7 Hepatitis Nursing Care Plans

June 10, 2012, 7:06 am

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Definition

Hepatitis is a widespread inflammation of the liver that results in degeneration and necrosis of liver cells. Inflammation of the liver can be due to bacterial invasion, injury by physical or toxic chemical agents (e.g., drugs, alcohol, industrial chemicals), viral infections (hepatitis A, B, C, D, E, G), or autoimmune response. Although most hepatitis is self-limiting, approximately 20% of acute hepatitis B and 50% of hepatitis C cases progress to a chronic state or cirrhosis and can be fatal.

Nursing Priorities

1. Reduce demands on liver while promoting physical well-being.
2. Prevent complications.
3. Enhance self-concept, acceptance of situation.
4. Provide information about disease process, prognosis, and treatment needs.

Discharge Goals

1. Meeting basic self-care needs.
2. Complications prevented/minimized.
3. Dealing with reality of current situation.
4. Disease process, prognosis, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.

Nursing Care Plans

This post includes 7 Hepatitis Nursing Care Plan (NCP).

Imbalanced Nutrition

NURSING DIAGNOSIS: Nutrition: imbalanced, less than body requirements

May be related to

• Insufficient intake to meet metabolic demands: anorexia, nausea/vomiting
• Altered absorption and metabolism of ingested foods: reduced peristalsis (visceral reflexes), bile stasis
• Increased calorie needs/hypermetabolic state

Possibly evidenced by

• Aversion to eating/lack of interest in food; altered taste sensation
• Abdominal pain/cramping
• Loss of weight; poor muscle tone

Desired Outcomes

• Initiate behaviors, lifestyle changes to regain/maintain appropriate weight.
• Demonstrate progressive weight gain toward goal with normalization of laboratory values and no signs of malnutrition.

Nursing Interventions	Rationale
Monitor dietary intake/calorie count. Suggest several small feedings and offer “largest” meal at breakfast.	Large meals are difficult to manage when patient is anorexic. Anorexia may also worsen during the day, making intake of food difficult later in the day.
Encourage mouth care before meals.	Eliminating unpleasant taste may enhance appetite.
Recommend eating in upright position.	Reduces sensation of abdominal fullness and may enhance intake.
Encourage intake of fruit juices, carbonated beverages, and hard candy throughout the day.	These supply extra calories and may be more easily digested/tolerated than other foods.
Consult with dietitian, nutritional support team to provide diet according to patient’s needs, with fat and protein intake as tolerated.	Useful in formulating dietary program to meet individual needs. Fat metabolism varies according to bile production and excretion and may necessitate restriction of fat intake if diarrhea develops. If tolerated, a normal or increased protein intake helps with liver regeneration. Protein restriction may be indicated in severe disease (e.g., fulminating hepatitis) because the accumulation of the end products of protein metabolism can potentiate hepatic encephalopathy.
Monitor serum glucose as indicated.	Hyperglycemia/hypoglycemia may develop, necessitating dietary changes/insulin administration. Fingerstick monitoring may be done by patient on a regular schedule to determine therapy needs.
Administer medications as indicated:Antiemetics, e.g., metoclopramide (Reglan), trimethobenzamide (Tigan);Antacids, e.g., Mylanta, Titralac;  Vitamins, e.g., B complex, C, other dietary supplements as indicated;   Steroid therapy, e.g., prednisone (Deltasone), alone or in combination with azathioprine (Imuran).	Given 1/2 hr before meals, may reduce nausea and increase food tolerance. Note: Prochlorperazine (Compazine) is contraindicated in hepatic disease.Counteracts gastric acidity, reducing irritation/risk of bleeding.Corrects deficiencies and aids in the healing process.  Steroids may be contraindicated because they can increase risk of relapse/development of chronic hepatitis in patients with viral hepatitis; however, anti-inflammatory effect may be useful in chronic active hepatitis (especially idiopathic) to reduce nausea/vomiting and enable patient to retain food and fluids. Steroids may decrease serum aminotransferase and bilirubin levels, but they do not affect liver necrosis or regeneration. Combination therapy has fewer steroid-related side effects.
Provide supplemental feedings/TPN if needed.	May be necessary to meet caloric requirements if marked deficits are present/symptoms are prolonged.

Deficient Fluid Volume

NURSING DIAGNOSIS: Fluid Volume, risk for deficient

Risk factors may include

• Excessive losses through vomiting and diarrhea, third-space shift
• Altered clotting process

Possibly evidenced by

• [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes

• Maintain adequate hydration, as evidenced by stable vital signs, good skin turgor, capillary refill, strong peripheral pulses, and individually appropriate urinary output.
• Be free of signs of hemorrhage with clotting times WNL.

Nursing Interventions	Rationale
Monitor I&O, compare with periodic weight. Note enteric losses, e.g., vomiting and diarrhea.	Provides information about replacement needs/effects of therapy. Note: Diarrhea may be due to transient flulike response to viral infection or may represent a more serious problem of obstructed portal blood flow with vascular congestion in the GI tract, or it may be the intended result of medication use (neomycin, lactulose) to decrease serum ammonia levels in the presence of hepatic encephalopathy.
Assess vital signs, peripheral pulses, capillary refill, skin turgor, and mucous membranes.	Indicators of circulating volume/perfusion.
Check for ascites for edema formation. Measure abdominal girth as indicated.	Useful in monitoring progression/resolution of fluid shifts (edema/ascites).
Use small-gauge needles for injections, applying pressure for longer than usual after venipuncture.	Reduces possibility of bleeding into tissues.
Have patient use cotton/sponge swabs and mouthwash instead of toothbrush.	Avoids trauma and bleeding of the gums.
Observe for signs of bleeding, e.g., hematuria/melena, ecchymosis, oozing from gums/puncture sites	Prothrombin levels are reduced and coagulation times prolonged when vitamin K absorption is altered in GI tract and synthesis of prothrombin is decreased in affected liver.
Monitor periodic laboratory values, e.g., Hb/Hct, Na, albumin, and clothing times.	Reflects hydration and identifies sodium retention/protein deficits, which may lead to edema formation. Deficits in clotting potentiate risk of bleeding/hemorrhage.
Administer antidiarrheal agents, e.g., diphenoxylate with atropine (Lomotil).	Reduces fluid/electrolyte loss from GI tract.
Provide IV fluids (usually glucose), electrolytes.Protein hydrolysates.	Provides fluid and electrolyte replacement in acute toxic state.
Administer medications as indicated, e.g.:Vitamin K;Antacids or H2-receptor antagonists, e.g., cimetidine (Tagamet).  Infuse fresh frozen plasma, as indicated.	Correction of albumin/protein deficits can aid in return of fluid from tissues to the circulatory system.Because absorption is altered, supplementation may prevent coagulation problems, which may occur if clotting factors/prothrombin time (PT) is depressed.Neutralize/reduce gastric secretions to lower risk of gastric irritation/bleeding.May be required to replace clotting factors in the presence of coagulation defects.

Low Self-Esteem

NURSING DIAGNOSIS: Self-Esteem, situational low

May be related to

• Annoying/debilitating symptoms, confinement/isolation, length of illness/recovery period

Possibly evidenced by

• Verbalization of change in lifestyle; fear of rejection/reaction of others, negative feelings about body; feelings of helplessness
• Depression, lack of follow-through, self-destructive behavior

Desired Outcomes

• Verbalize feelings.
• Identify feelings and methods for coping with negative perception of self.
• Verbalize acceptance of self in situation, including length of recovery/need for isolation.
• Acknowledge self as worthwhile; be responsible for self.

Nursing Interventions	Rationale
Contract with patient regarding time for listening. Encourage discussion of feelings/concerns.	Establishing time enhances trusting relationship. Providing opportunity to express feelings allows patient to feel more in control of the situation. Verbalization can decrease anxiety and depression and facilitate positive coping behaviors. Patient may need to express feelings about being ill, length and cost of illness, possibility of infecting others, and (in severe illness) fear of death. May have concerns regarding the stigma of the disease.
Avoid making moral judgments regarding lifestyle (e.g., alcohol use/sexual practices).	Patient may already feel upset/angry and condemn self; judgments from others will further damage self-esteem.
Discuss recovery expectations.	Recovery period may be prolonged (up to 6 mo), potentiating family/situational stress and necessitating need for planning, support, and follow-up.
Assess effect of illness on economic factors of patient/SO.	Financial problems may exist because of loss of patient’s role functioning in the family/prolonged recovery.
Offer diversional activities based on energy level.	Enables patient to use time and energy in constructive ways that enhance self-esteem and minimize anxiety and depression.
Suggest patient wear bright reds or blues/blacks instead of yellows or greens.	Enhances appearance, because yellow skin tones are intensified by yellow/green colors. Note: Jaundice usually peaks within 1–2 wk, then gradually resolves over 2–4 wk.
Make appropriate referrals for help as needed, e.g., case manager/discharge planner, social services, and/or other community agencies.	Can facilitate problem solving and help involved individuals cope more effectively with situation.

Risk for Infection

NURSING DIAGNOSIS: Infection, risk for

Risk factors may include

• Inadequate secondary defenses (e.g., leukopenia, suppressed inflammatory response) and immunosuppression
• Malnutrition
• Insufficient knowledge to avoid exposure to pathogens

Possibly evidenced by

• [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes

• Verbalize understanding of individual causative/risk factor(s).
• Demonstrate techniques; initiate lifestyle changes to avoid reinfection/transmission to others.

Nursing Interventions	Rationale
Establish isolation techniques for enteric and respiratory infections according to infection guidelines/policy. Encourage/model effective handwashing.	Prevents transmission of viral disease to others. Thorough handwashing is effective in preventing virus transmission. Types A and E are transmitted by oral-fecal route, contaminated water, milk, and food (especially inadequately cooked shellfish). Types A, B, C, and D are transmitted by contaminated blood/blood products; needle punctures; open wounds; and contact with saliva, urine, stool, and semen. Incidence of both hepatitis B virus (HBV) and hepatitis C virus (HCV) has increased among healthcare providers and high-risk patients. Note: Toxic and alcoholic hepatitis are not communicable and do not require special measures/isolation.
Stress need to monitor/restrict visitors as indicated.	Patient exposure to infectious processes (especially respiratory) potentiates risk of secondary complications.
Explain isolation procedures to patient/SO.	Understanding reasons for safeguarding themselves and others can lessen feelings of isolation and stigmatization. Isolation may last 2–3 wk from onset of illness, depending on type/duration of symptoms.
Give information regarding availability of gamma globulin, ISG, H-BIG, HB vaccine (Recombivax HB, Engerix-B) through health department or family physician	Immune globulins may be effective in preventing viral hepatitis in those who have been exposed, depending on type of hepatitis and period of incubation.
Administer medications as indicated:Antiviral drugs: vidarabine (Vira-A), acyclovir (Zovirax);Interferon alfa-2b (Intron A);Ribavirin;       Antibiotics appropriate to causative agents (e.g., Gram-negative, anaerobic bacteria) or secondary process.	Useful in treating chronic active hepatitis.Treats the symptoms of hepatitis C and may lead to temporary improvement in liver function.Used in conjunction with interferon to improve the effectiveness of that drug. Note: These treatments lead to improvement, not cure of the disease.  Used to treat bacterial hepatitis or to prevent/limit secondary infections.

Fatigue

NURSING DIAGNOSIS: Fatigue

May be related to

• Decreased metabolic energy production
• States of discomfort
• Altered body chemistry (e.g., changes in liver function, effect on target organs)

Possibly evidenced by

• Reports of lack of energy/inability to maintain usual routines.
• Decreased performance
• Increase in physical complaints

Desired Outcomes

• Report improved sense of energy.
• Perform ADLs and participate in desired activities at level of ability.

Nursing Interventions	Rationale
Promote bedrest/chair (recliner) rest during toxic state. Provide quiet environment; limit visitors as needed.	Promotes rest and relaxation. Available energy is used for healing. Activity and an upright position are believed to decrease hepatic blood flow, which prevents optimal circulation to the liver cells.
Recommend changing position frequently. Provide/instruct caregiver in good skin care.	Promotes optimal respiratory function and minimizes pressure areas to reduce risk of tissue breakdown.
Do necessary tasks quickly and at one time as tolerated.	Allows for extended periods of uninterrupted rest.
Determine and prioritize role responsibilities and alternative providers/possible community resources available	Promotes problem solving of most pressing needs of individual/family.
Identify energy-conserving techniques, e.g., sitting to shower and brush teeth, planning steps of activity so that all needed materials are at hand, scheduling rest periods.	Helps minimize fatigue, allowing patient to accomplish more and feel better about self.
Increase activity as tolerated, demonstrate passive/active ROM exercises.	Prolonged bedrest can be debilitating. This can be offset by limited activity alternating with rest periods.
Encourage use of stress management techniques, e.g., progressive relaxation, visualization, guided imagery. Discuss appropriate diversional activities, e.g., radio, TV, reading	Promotes relaxation and conserves energy, redirects attention, and may enhance coping.
Monitor for recurrence of anorexia and liver tenderness/ enlargement.	Indicates lack of resolution/exacarbation of the disease, requiring further rest, change in therapeutic regimen.
Administer medications as indicted: sedatives, antianxiety agents, e.g., diazepam (Valium), lorazepam (Ativan).	Assists in managing required rest. Note: Use of barbiturates and antianxiety agents, such as prochlorperazine (Compazine) and chlorpromazine (Thorazine), is contraindicated because of hepatotoxic effects.
Monitor serial liver enzyme levels.	Aids in determining appropriate levels of activity because premature increase in activity potentiates risk of relapse.
Administer antidote or assist with inpatient procedures as indicated (e.g., lavage, catharsis, hyperventilation) depending on route of exposure.	Removal of causative agent in toxic hepatitis may limit degree of tissue involvement/damage.

Impaired Skin Integrity

NURSING DIAGNOSIS: Skin/Tissue Integrity, risk for impaired

Risk factors may include

• Chemical substance: bile salt accumulation in the tissues

Possibly evidenced by

• [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes

• Display intact skin/tissues, free of excoriation.
• Report absence/decrease of pruritus/scratching.

Nursing Interventions	Rationale
Encourage use of cool showers and baking soda or starch baths. Avoid use of alkaline soaps. Apply calamine lotion as indicated.	Prevents excessive dryness of skin. Provides relief from itching.
Provide diversional activities.	Aids in refocusing attention, reducing tendency to scratch.
Suggest use of knuckles if desire to scratch is uncontrollable. Keep fingernails cut short, apply gloves on comatose patient or during hours of sleep. Recommend loose-fitting clothing. Provide soft cotton linens.	Reduces potential for dermal injury.
Provide a soothing massage at bedtime.	May be helpful in promoting sleep by reducing skin irritation.
Observe skin for areas of redness, breakdown.	Early detection of problem areas allows for additional intervention to prevent complications/promote healing.
Avoid comments regarding patient’s appearance.	Minimizes psychological stress associated with skin changes.
Administer medications as indicated:Antihistamines, e.g., diphenhydramine (Benadryl), azatadine (optimine);Antilipemics, e.g., cholestyramine (Questran).	Relieves itching. Note: Use cautiously in severe hepatic disease.May be used to bind bile acids in the intestine and prevent their absorption. Note side effects of nausea and constipation.

Knowledge Deficit

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs

May be related to

• Lack of exposure/recall; information misinterpretation
• Unfamiliarity with resources

Possibly evidenced by

• Questions or statements of misconception; request for information
• Inaccurate follow-through of instructions; development of preventable complications

Desired Outcomes

• Verbalize understanding of disease process, prognosis, and potential complications.
• Identify relationship of signs/symptoms to the disease and correlate symptoms with causative factors.
• Verbalize understanding of therapeutic needs.
• Initiate necessary lifestyle changes and participate in treatment regimen.

Nursing Interventions	Rationale
Assess level of understanding of the disease process, expectations/prognosis, possible treatment options.	Identifies areas of lack of knowledge/misinformation and provides opportunity to give additional information as necessary. Note: Liver transplantation may be needed in the presence of fulminating disease with liver failure.
Provide specific information regarding prevention/transmission of disease, e.g., contacts may require gamma-globulin; personal items should not be shared; observe strict handwashing and sanitizing of clothes, dishes, and toilet facilities while liver enzymes are elevated. Avoid intimate contact, such as kissing and sexual contact, and exposure to infections, especially URI.	Needs/recommendations vary with type of hepatitis (causative agent) and individual situation.
Plan resumption of activity as tolerated with adequate periods of rest. Discuss restriction of heavy lifting, strenous exercise/contact sports.	It is not necessary to wait until serum bilirubin levels return to normal to resume activity (may take as long as 2 mo), but strenuous activity needs to be limited until the liver returns to normal size. When patient begins to feel better, he or she needs to understand the importance of continued adequate rest in preventing relapse or recurrence. (Relapse occurs in 5%–25% of adults.)Note: Energy level may take up to 3–6 mo to return to normal.
Help patient identify appropriate diversional activities.	Enjoyable activities promote rest and help patient avoid focusing on prolonged convalescence.
Encourage continuation of balanced diet.	Promotes general well-being and enhances energy for healing process/tissue regeneration.
Identify ways to maintain usual bowel function, e.g., adequate intake of fluids/dietary roughage, moderate activity/exercise to tolerance.	Decreased level of activity, changes in food/fluid intake, and slowed bowel motility may result in constipation.
Discuss the side effects and dangers of taking OTC/prescribed drugs (e.g., acetaminophen, aspirin, sulfonamides, some anesthetics) and necessity of notifying future healthcare providers of diagnosis.	Some drugs are toxic to the liver; many others are metabolized by the liver and should be avoided in severe liver diseases because they may cause cumulative toxic effects/chronic hepatitis.
Discuss restrictions on donating blood.	Prevents spread of infectious disease. Most state laws prevent accepting as donors those who have a history of any type of hepatitis.
Emphasize importance of follow-up physical examination and laboratory evaluation.	Disease process may take several months to resolve. If symptoms persist longer than 6 mo, liver biopsy may be required to verify presence of chronic hepatitis.
Review necessity of avoidance of alcohol for a minimum of 6–12 mo or longer based on individual tolerance.	Increases hepatic irritation and may interfere with recovery.
Refer to community resources, drug/alcohol treatment program as indicated.	May need additional assistance to withdraw from substance and maintain abstinence to avoid further liver damage.

Other Possible Nursing Diagnoses

1. Fatigue—generalized weakness, decreased strength/endurance, pain, imposed activity restrictions, depression.
2. Home Maintenance, impaired—prolonged recovery/chronic condition, insufficient finances, inadequate support systems, unfamiliarity with neighborhood resources.
3. Nutrition: imbalanced, less than body requirements—insufficient intake to meet metabolic demands: anorexia, nausea/vomiting; altered absorption and metabolism of ingested foods; increased calorie needs/hypermetabolic state.
4. Infection, risk for—inadequate secondary defenses; malnutrition; insufficient knowledge to avoid exposure to pathogens.

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Respiratory Alkalosis

April 30, 2013, 11:36 am

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Respiratory Alkalosis is an acid-base imbalance characterized by decreased partial pressure of arterial carbon dioxide and increased blood pH to less than 35 mm Hg, which is due to alveolar hyperventilation.

16+ Heart Failure Nursing Care Plans

July 14, 2013, 4:50 am

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Heart failure is a physiologic state in which he heart cannot pump enough blood to meet the metabolic needs of the body. Here are 16+ nursing care plans (NCP) for patients with Congestive Heart Failure:

8 Liver Cirrhosis Nursing Care Plans

July 14, 2013, 10:10 pm

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Nursing care planning for patients with liver cirrhosis includes promoting rest, providing adequate nutrition, skin care, reducing risk for injury, and monitoring and managing complications.  Here are 8 liver cirrhosis nursing care plans (NCP):

10 Fluid And Electrolyte Imbalances Nursing Care Plans

April 25, 2017, 9:01 am

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Nursing plan and goals for fluid and electrolyte imbalances include: maintaining fluid volume at a functional level, patient exhibits normal laboratory values, demonstrates appropriate changes in lifestyle and behaviors including eating patterns and food quantity/quality, re-establishing and maintaining normal pattern and GI functioning.

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5 Nephrotic Syndrome Nursing Care Plans

June 12, 2018, 5:00 pm

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Nursing care planning for a client with nephrotic syndrome include relief from edema, enhance nutritional status, conserve energy...Here are five (5) nursing care plans (NCP) for Nephrotic Syndrome.

6 Peritonitis Nursing Care Plans

February 26, 2014, 5:35 pm

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Peritonitis is the inflammation of the peritoneal cavity. It is either caused by bacteria or chemicals, can either be primary or secondary, and acute or chronic. Here are 6 nursing care plans for Peritonitis.

8+ Pancreatitis Nursing Care Plans

February 27, 2014, 5:40 pm

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Pancreatitis is a painful inflammatory condition in which the pancreatic enzymes are prematurely activated resulting in autodigestion of the pancreas.

FULL-TEXT: Fundamentals of Nursing NCLEX Practice Quiz (600 Questions)

December 31, 2019, 9:00 am

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This is the full-text copy of the 100-item quiz Select All That Apply NCLEX Practice Questions. Use this page to print a copy of the quiz or export it via PDF.

FULL-TEXT: NCLEX-RN Practice Quiz Test Bank (900 Questions)

December 31, 2019, 9:00 am

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This is the full-text copy of the 900-item quiz NCLEX-RN Practice Quiz Test Bank. Use this page to print a copy of the quiz or export it via PDF.