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Jennifer Laws, Clinical Care Plan September 12, 2020

ASSESSMENT DATA List as much pertinent data that supports the Nursing Diagnosis. Subjective Data (S): Data client (or family) tells us (quotes OK). Objective (O): Data we measure, or “see,” or retrieve from client hx., procedures, diagnostics, labs, etc.

S: Wife states patient has slight confusion x4 days; restless bleeding gums x2 days O: Patient appears jaundiced; confused; mild ascites; T: 98.4 R: 22 BP: 130/86; SPO2: 92; SBR: 3.1; crackles upon auscultating lungs

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NURSING DIAGNOSIS NANDA DX Format: Use only approved NANDA Diagnoses, with “related to” and “AEB” Include pertinent evidence-based practice rationale/pathophysiol ogy/definition with proper APA in-text reference after each

PLANNING (“What will be done?”) List 1 total short term and 1 long term client goal (STG/LTG) per nursing dx; preferably short term goals that can be accomplished “by end of shift” Must be measureable, realistic, and achievable client centered goals Number and list planned interventions (minimum of 3) each with delegation (who can perform in parentheses at end of each intervention).

Nursing Diagnosis # 1 (Physiological): Excess fluid volume, extravascular (Ascites) related to compromised regulatory mechanisms of liver aeb mild ascites and crackles when auscultating lungs

STG#1: Patient is normovolemic as evidenced by urine output greater than or equal to 30 ml/hr by end of shift.

Etiology/Rationale: “Ascites is a third space collection of proteinrich fluid in the

NURSING IMPLEMENTATION (“What was actually done?”) Across from corresponding number in previous column, describe each implementation and who performed. List evidence-based practice rationale (R), and proper APA in-text reference for each rationale entry.

Evaluate each goal by stating either: Goal met/Partially met/Not met. For Partially Met/Not Met Goals, indicate your recommendations or revisions to care plan Pertinent Subjective (S) & Objective (O) Data for each goal evaluation. STG #1: Goal met by end of shift aeb urine output 31 ml/hr. S: Patient states: “I do not feel swollen.”

LTG#1: Patient has clear lung sounds as manifested by absence of pulmonary crackles by discharge Interventions (minimum of 3):

Implementation: 1.

1. Monitor the patient’s fluid intake, urinary output, and

EVALUATION

Monitored fluid intake, urinary output, and body weight

O: No ascites observed and urine output 31 ml/hr.

LTG#1: Goal met by

Jennifer Laws, Clinical Care Plan September 12, 2020

ASSESSMENT DATA List as much pertinent data that supports the Nursing Diagnosis. Subjective Data (S): Data client (or family) tells us (quotes OK). Objective (O): Data we measure, or “see,” or retrieve from client hx., procedures, diagnostics, labs, etc.

NURSING DIAGNOSIS NANDA DX Format: Use only approved NANDA Diagnoses, with “related to” and “AEB” Include pertinent evidence-based practice rationale/pathophysiol ogy/definition with proper APA in-text reference after each

peritoneal cavity. Its volume may be so severe as to impair respiratory and digestive functions, as well as mobility.” (Gulanick and Myers, 2017)

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PLANNING (“What will be done?”) List 1 total short term and 1 long term client goal (STG/LTG) per nursing dx; preferably short term goals that can be accomplished “by end of shift” Must be measureable, realistic, and achievable client centered goals Number and list planned interventions (minimum of 3) each with delegation (who can perform in parentheses at end of each intervention).

body weight Delegated: LPN 2. Assess Breathing Patterns Delegated: RN 3. Monitor serum albumin Delegated: RN

NURSING IMPLEMENTATION (“What was actually done?”) Across from corresponding number in previous column, describe each implementation and who performed. List evidence-based practice rationale (R), and proper APA in-text reference for each rationale entry.

Rationale: “Although overall intake of fluid may be adequate, a shifting of fluid out of the intravascular space and into the extra-vascular spaces may result in dehydration.” (Gulanick and Myers, 2017) 2. Assessed Breathing Rationale: “Actions may limit the excursion of the diaphragm on inspiration. The patient may hypo

EVALUATION Evaluate each goal by stating either: Goal met/Partially met/Not met. For Partially Met/Not Met Goals, indicate your recommendations or revisions to care plan Pertinent Subjective (S) & Objective (O) Data for each goal evaluation. discharge aeb no crackles upon auscultating lungs. S: Patient states “feel like I can breathe better.” O: Patient’s breathing unlabored, lungs sound clear upon auscultating and vital signs all within normal limits.

Jennifer Laws, Clinical Care Plan September 12, 2020

ASSESSMENT DATA List as much pertinent data that supports the Nursing Diagnosis. Subjective Data (S): Data client (or family) tells us (quotes OK). Objective (O): Data we measure, or “see,” or retrieve from client hx., procedures, diagnostics, labs, etc.

NURSING DIAGNOSIS NANDA DX Format: Use only approved NANDA Diagnoses, with “related to” and “AEB” Include pertinent evidence-based practice rationale/pathophysiol ogy/definition with proper APA in-text reference after each

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PLANNING (“What will be done?”) List 1 total short term and 1 long term client goal (STG/LTG) per nursing dx; preferably short term goals that can be accomplished “by end of shift” Must be measureable, realistic, and achievable client centered goals Number and list planned interventions (minimum of 3) each with delegation (who can perform in parentheses at end of each intervention).

NURSING IMPLEMENTATION (“What was actually done?”) Across from corresponding number in previous column, describe each implementation and who performed. List evidence-based practice rationale (R), and proper APA in-text reference for each rationale entry.

ventilate in a supine position.” (Gulanick and Myers, 2017) 3. Monitored serum albumin Rationale: Protein Molecules act as fluid “magnets” that help maintain body fluid in the correct compartments; low serum protein levels allow a shift of fluid to

EVALUATION Evaluate each goal by stating either: Goal met/Partially met/Not met. For Partially Met/Not Met Goals, indicate your recommendations or revisions to care plan Pertinent Subjective (S) & Objective (O) Data for each goal evaluation.

Jennifer Laws, Clinical Care Plan September 12, 2020

ASSESSMENT DATA List as much pertinent data that supports the Nursing Diagnosis. Subjective Data (S): Data client (or family) tells us (quotes OK). Objective (O): Data we measure, or “see,” or retrieve from client hx., procedures, diagnostics, labs, etc.

NURSING DIAGNOSIS NANDA DX Format: Use only approved NANDA Diagnoses, with “related to” and “AEB” Include pertinent evidence-based practice rationale/pathophysiol ogy/definition with proper APA in-text reference after each

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PLANNING (“What will be done?”) List 1 total short term and 1 long term client goal (STG/LTG) per nursing dx; preferably short term goals that can be accomplished “by end of shift” Must be measureable, realistic, and achievable client centered goals Number and list planned interventions (minimum of 3) each with delegation (who can perform in parentheses at end of each intervention).

NURSING IMPLEMENTATION (“What was actually done?”) Across from corresponding number in previous column, describe each implementation and who performed. List evidence-based practice rationale (R), and proper APA in-text reference for each rationale entry.

EVALUATION Evaluate each goal by stating either: Goal met/Partially met/Not met. For Partially Met/Not Met Goals, indicate your recommendations or revisions to care plan Pertinent Subjective (S) & Objective (O) Data for each goal evaluation.

the extravascular space of the abdominal cavity from vascular and interstitial spaces.” (Gulanick and Myers, 2017)

S: Wife states patient has slight confusion x4 days; bleeding gums x2 days; wife states he has been fatigued and weak

Nursing Diagnosis # 2 (safety): Risk for bleeding related to altered liver function; low Hgb and bleeding

STG#1: Patient implements measures to prevent bleeding and identifies signs of bleeding that need to be reported immediately to a health care provider by end of

STG #1: Goal met by end of shift educated patient about signs of bleeding in stools, using

Jennifer Laws, Clinical Care Plan September 12, 2020

ASSESSMENT DATA List as much pertinent data that supports the Nursing Diagnosis. Subjective Data (S): Data client (or family) tells us (quotes OK). Objective (O): Data we measure, or “see,” or retrieve from client hx., procedures, diagnostics, labs, etc.

O: Patient appears jaundiced; history of EtOH abuse x25 years; T: 98.4 R: 22 BP: 130/86; SPO2: 92; SBR: 3.1; Hgb 6.0 g/dL

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NURSING DIAGNOSIS NANDA DX Format: Use only approved NANDA Diagnoses, with “related to” and “AEB” Include pertinent evidence-based practice rationale/pathophysiol ogy/definition with proper APA in-text reference after each

PLANNING (“What will be done?”) List 1 total short term and 1 long term client goal (STG/LTG) per nursing dx; preferably short term goals that can be accomplished “by end of shift” Must be measureable, realistic, and achievable client centered goals Number and list planned interventions (minimum of 3) each with delegation (who can perform in parentheses at end of each intervention).

of gums x2 days

shift. (Gulanick and Myers, 2017)

Etiology/Rationale: “Early Identification of potential risks for bleeding provides a basis for implementing appropriate preventive measures.” (Gulanick and Myers, 2017)

NURSING IMPLEMENTATION (“What was actually done?”) Across from corresponding number in previous column, describe each implementation and who performed. List evidence-based practice rationale (R), and proper APA in-text reference for each rationale entry.

1. Monitor BP and HR. Delegated: CNA 2. Monitor hematocrit and

Evaluate each goal by stating either: Goal met/Partially met/Not met. For Partially Met/Not Met Goals, indicate your recommendations or revisions to care plan Pertinent Subjective (S) & Objective (O) Data for each goal evaluation. a soft toothbrush for brushing teeth and informing health care provider of any signs.

LTG#1: Patient does not experience bleeding aeb stable hemoglobin and hematocrit levels by discharge. (Gulanick and Myers, 2017) Interventions (minimum of 3):

EVALUATION

Implementations:

S: Patient’s wife states: “I will monitor stools and already bought my husband a soft toothbrush.”

1. Monitored BP and HR Rationales: “Tachycardia and hypotension are initial

O: Patient and wife fully understood instructions.

Jennifer Laws, Clinical Care Plan September 12, 2020

ASSESSMENT DATA List as much pertinent data that supports the Nursing Diagnosis. Subjective Data (S): Data client (or family) tells us (quotes OK). Objective (O): Data we measure, or “see,” or retrieve from client hx., procedures, diagnostics, labs, etc.

NURSING DIAGNOSIS NANDA DX Format: Use only approved NANDA Diagnoses, with “related to” and “AEB” Include pertinent evidence-based practice rationale/pathophysiol ogy/definition with proper APA in-text reference after each

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PLANNING (“What will be done?”) List 1 total short term and 1 long term client goal (STG/LTG) per nursing dx; preferably short term goals that can be accomplished “by end of shift” Must be measureable, realistic, and achievable client centered goals Number and list planned interventions (minimum of 3) each with delegation (who can perform in parentheses at end of each intervention).

NURSING IMPLEMENTATION (“What was actually done?”) Across from corresponding number in previous column, describe each implementation and who performed. List evidence-based practice rationale (R), and proper APA in-text reference for each rationale entry.

hemoglobin Delegated: RN 3. Monitor stool and urine for signs of blood Delegated: RN

compensatory mechanisms common noted with bleeding. Orthostatic (a drop of 20mm Hg in systolic BP or 10 mm Hg in diastolic BP when changing from supine to sitting position) indicates reduced circulating fluids.” (Gulanick and Myers, 2017) 2. Monitored hematocrit and hemoglobin Delegated:

EVALUATION Evaluate each goal by stating either: Goal met/Partially met/Not met. For Partially Met/Not Met Goals, indicate your recommendations or revisions to care plan Pertinent Subjective (S) & Objective (O) Data for each goal evaluation.

LTG #1: Goal met by discharge aeb vital signs, hemoglobin and hematocrit all within normal limits. S: Patient states: “I haven’t seen any blood when brushing teeth.” O: No signs of bleeding in stools or while

Jennifer Laws, Clinical Care Plan September 12, 2020

ASSESSMENT DATA List as much pertinent data that supports the Nursing Diagnosis. Subjective Data (S): Data client (or family) tells us (quotes OK). Objective (O): Data we measure, or “see,” or retrieve from client hx., procedures, diagnostics, labs, etc.

NURSING DIAGNOSIS NANDA DX Format: Use only approved NANDA Diagnoses, with “related to” and “AEB” Include pertinent evidence-based practice rationale/pathophysiol ogy/definition with proper APA in-text reference after each

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PLANNING (“What will be done?”) List 1 total short term and 1 long term client goal (STG/LTG) per nursing dx; preferably short term goals that can be accomplished “by end of shift” Must be measureable, realistic, and achievable client centered goals Number and list planned interventions (minimum of 3) each with delegation (who can perform in parentheses at end of each intervention).

NURSING IMPLEMENTATION (“What was actually done?”) Across from corresponding number in previous column, describe each implementation and who performed. List evidence-based practice rationale (R), and proper APA in-text reference for each rationale entry.

RN Rationale: “When bleeding is not visible, decreased Hgb and Hct levels may be an early indicator of bleeding.” (Gulanick and Myers, 2017) 3. Monitored stool and urine for signs of blood. Rationale: “These tests are used to detect bleeding from the gastrointestinal or urinary tracts that may not be visible.” (Gulanick

EVALUATION Evaluate each goal by stating either: Goal met/Partially met/Not met. For Partially Met/Not Met Goals, indicate your recommendations or revisions to care plan Pertinent Subjective (S) & Objective (O) Data for each goal evaluation. brushing teeth, vitals all within normal limits, hematocrit, and hemoglobin within normal limits.

Jennifer Laws, Clinical Care Plan September 12, 2020

ASSESSMENT DATA List as much pertinent data that supports the Nursing Diagnosis. Subjective Data (S): Data client (or family) tells us (quotes OK). Objective (O): Data we measure, or “see,” or retrieve from client hx., procedures, diagnostics, labs, etc.

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NURSING DIAGNOSIS NANDA DX Format: Use only approved NANDA Diagnoses, with “related to” and “AEB” Include pertinent evidence-based practice rationale/pathophysiol ogy/definition with proper APA in-text reference after each

PLANNING (“What will be done?”) List 1 total short term and 1 long term client goal (STG/LTG) per nursing dx; preferably short term goals that can be accomplished “by end of shift” Must be measureable, realistic, and achievable client centered goals Number and list planned interventions (minimum of 3) each with delegation (who can perform in parentheses at end of each intervention).

Nursing Diagnosis # 3 (Psycho/social, spiritual, cultural: Risk for Chronic confusion related to etoH, high ammonia levels and confusion

STG#1: Patient able to state name by end of shift.

NURSING IMPLEMENTATION (“What was actually done?”) Across from corresponding number in previous column, describe each implementation and who performed. List evidence-based practice rationale (R), and proper APA in-text reference for each rationale entry.

EVALUATION Evaluate each goal by stating either: Goal met/Partially met/Not met. For Partially Met/Not Met Goals, indicate your recommendations or revisions to care plan Pertinent Subjective (S) & Objective (O) Data for each goal evaluation.

and Myers, 2017). S: Wife states patient has not been able to relay normal information to her does not remember everyday things, doesn’t seem to know what is going on around him. O: Patient appears is not aware of time and date; history of EtOH abuse x25 years and

Etiology/Rationale: Confusion may be caused by alcohol intoxication or hepatic encephalopathy.

LTG#1: Patient has normal ammonia levels by end of discharge and able to state, name, time and date by discharge. Interventions (minimum of 3): 1. Monitor blood ammonia levels. Delegated: RN

STG #1: Goal met patient able to state name by end of shift. S: Patient’s wife states: “I am so happy to see that my husband is alert.” Implementations:

1. Monitored blood ammonia levels.

O: Patient alert and able to state name. LTG#1: LTG met by discharge patient is

Jennifer Laws, Clinical Care Plan September 12, 2020

ASSESSMENT DATA List as much pertinent data that supports the Nursing Diagnosis. Subjective Data (S): Data client (or family) tells us (quotes OK). Objective (O): Data we measure, or “see,” or retrieve from client hx., procedures, diagnostics, labs, etc.

chronic liver disease; NH3 89; T: 98.4 R: 22 BP: 130/86; SPO2: 94; SBR: 3.1

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NURSING DIAGNOSIS NANDA DX Format: Use only approved NANDA Diagnoses, with “related to” and “AEB” Include pertinent evidence-based practice rationale/pathophysiol ogy/definition with proper APA in-text reference after each

PLANNING (“What will be done?”) List 1 total short term and 1 long term client goal (STG/LTG) per nursing dx; preferably short term goals that can be accomplished “by end of shift” Must be measureable, realistic, and achievable client centered goals Number and list planned interventions (minimum of 3) each with delegation (who can perform in parentheses at end of each intervention).

NURSING IMPLEMENTATION (“What was actually done?”) Across from corresponding number in previous column, describe each implementation and who performed. List evidence-based practice rationale (R), and proper APA in-text reference for each rationale entry.

“Hepatic encephalopathy typically occurs in endstate liver disease. The accumulation of ammonia and other neurological toxins can impair thinking and neuromuscular function.” (Gulanick and Myers, 2017)

2. Consult with members of the interprofessional health team about measures to decrease the sources of dietary ammonia. Delegated: RN 3. Assess for signs and symptoms of hepatic encephalopathy Delegated: RN

Rationale: Normally, ammonia is produced in the colon by the interaction of amino acids and colonic bacteria, metabolized by the liver and excreted. Patients with cirrhosis may lack the hepatic ability to metabolized ammonia, which accumulates and acts as a cerebral toxin.” (Gulanick and Myers, 2017) 2. Consulted with members of the interprofessional

EVALUATION Evaluate each goal by stating either: Goal met/Partially met/Not met. For Partially Met/Not Met Goals, indicate your recommendati...