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LIVER CIRRHOSIS ACUTE ANEMIA
SECONDARY TOUPPER GASTROINTESTINAL BLEEDING
In partial fulfillment of the requirements in NURS65b Medical Surgical Nursing
Submitted to the level III Clinical Instructors of the College of Nursing,
Cavite State University, Indang, Cavite
Presented by:
BSN Level III/Group2
Al-ghorani, Areej S.
Dimaranan, Zaira Joy D.
Foliente, Jayson P.Jaleco, Cristy Belle D.
Losoloso, Bethlehem
Marqueda, Jessa
Redruco, Nheafe Reden
Salamatin, Anna Marie L.
Sarabia, Rachelline
Trupel, Janah Nicole
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ABSTRACT
We, BSN 3 section 1, group 2 chose Liver Cirrhosis, AcuteAnemia secondary to UGIB as our case for the case presentationbecause this is the patient who had the most significant disease outof all the patients that we handled in GEAMH medical ward during
our threeday shift. This patient is challenging for us because weneed deeper understanding and proper management in order toprovide a safe and quality nursing care.
The purpose of this case study is to learn the disease process,its management, medications and treatment. Here is a briefintroduction and overview of what Liver cirrhosisis all about.
Cirrhosis is a complication of many liver diseasesthat ischaracterized by abnormal structure and function of the liver. Thediseases that lead to cirrhosis do so because they injure and killliver cells and the inflammation and repair that is associated withthe dying liver cells causes scar tissue to form.
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The liver cells that do not die multiply in an attempt toreplace the cells that have died. This results in clustersof newly-formed liver cells (regenerative nodules)
within the scar tissue. There are many causes ofcirrhosis; they include chemicals (such as alcohol, fat,and certain medications), viruses, toxic metals (such asiron and copper that accumulate in the liver as a result
of geneticdiseases), and autoimmuneliver diseaseinwhich the body's immune systemattacks the liver.Patients with cirrhosis may have few or no symptomsand signs of liver disease. Some of the symptoms may
be nonspecific, that is, they don't suggest that the liveris their cause. Some of the more common symptomsand signs of cirrhosis include: Yellowing of the skin(jaundice) due to the accumulation of bilirubinin
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the blood, Fatigue, Weakness, Loss of appetite, Itching, and Easy
bruisingand bleeding from decreased production of blood clotting
factors by the diseased liver.
Alcohol is a very common cause of cirrhosis, particularly in the
Western world. The development of cirrhosis depends upon the
amount and regularity of alcohol intake. Chronic, high levels of
alcohol consumption injure liver cells. Thirty percent of individuals
who drink daily at least eight to sixteen ounces of hard liquor or the
equivalent for fifteen or more years will develop cirrhosis. Alcohol
causes a range of liver diseases; from simple and uncomplicated fatty
liver(steatosis), to the more serious fatty liver with inflammation
(steatohepatitisor alcoholic hepatitis), to cirrhosis. Our patient manifested some of the symptoms of Liver cirrhosis
specifically bleeding. He had been excessively drinking alcoholic
beverages which lead to his condition. His condition will be further
evaluated and assessed as we go along in this case study.
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Initials of the client: R.R.A.
Address: 1B Malagasang Imus Cavite Date of Interview: March 13, 2013 4:00 p.m.
Age: 49 years old Primary Informant: R.R.A.
Birth date: June 20, 1963 Other Data Sources: Patients Chart
Birth Place: Pabella Sta. Cruz Blood Type: O Rh(+)
Gender: Male Civil Status: Single
Religion: Roman Catholic
Highest Educational Attainment: High School Graduate
Current Occupation: Pedicab Driver
Monthly Family Income/Budget: pesos
Everyday Income: Php250-Php300
Income allotment: * Electric bills- Php500-Php700
* Water bills- Php150-Php250
* Food Allowance-Php500-Php1000
*Everyday Expenses- Php200-Php250
Usual Source of Medical Care: Hospital check-ups
Medical Support: Philhealth
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March 9, 2013, 8:35 in the evening patient
R.R.A. was admitted in General EmilioAguinaldo Hospital with his brother as a new
patient due to passing bloody stools and
abdominal pain.
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January 2010, patient was first admitted in Philippine GeneralHospital due to abdominal pain. He was diagnosed with a liverproblem. June 2010, patient had a fever and experiencedrecurrent abdominal pain and bloated stomach, but did notconsult any medical advice and care. He did not visit followup check up. He stayed at home until his stomach subsides.March 2013, a week prior to hospitalization R.R.A. drank
alcohol. 2 days PTA patient had abdominal pain. 1 day PTA, patient had
continuous abdominal pain associated with bloody stools. Hewas sent to the emergency room of GEAMH at 8:35 pm onMarch 9, 2013.
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PAST MEDICAL HISTORY
The patient does not have any serious childhood diseases except formeasles; he also had coughs and colds like any other child.According to thepatient, he had complete immunizations when he was a child. He already had 1dose of Tetanus toxoid due to his current accident. The patient has no knownallergies.
February 7, 2013, at exactly 7:00 a.m. he was hit and run by a motor vehiclewith slight lesions on his extremities and does not go to hospitals instead he stayedat home and rested there with his mother taking care of him. March 3, 2013 in theevening, while R.R.A. is drunk and riding his bicycle, the patient had an accidentand fell, and hit his head. The patient was sent to General Emilio AguinaldoHospital for treatment.
He was first hospitalized at Philippine General Hospital on June, 2010 and
was diagnosed with Liver dysfunction. Second hospitalization was at GeneralEmilio Aguinaldo Hospital on March 9, 2013 due to liver Cirrhosis. The patient hadnot undergone any operations and surgeries as of now. The clients medication areas follows: Vit. K, Tranexamic Acid, Rebamipide, Moriamin forte-calciumpantothenic, Livoline, albumin, furosemide, lactulose and omeprazole.
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I. Health PerceptionHealth ManagementPattern
II. Nutritional Metabolic Pattern III. Elimination Pattern
IV. Activity Exercise Pattern
V. SleepRest Pattern
VI. Cognitive Perceptual Pattern
VII. Self- Perception Pattern
VIII. Role Relationship Pattern
IX. Coping Stress Pattern
X. Value Belief Pattern
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I. Health PerceptionHealth
Management Pattern
Patient R.R.A. perceives health as important part in his life and said
that he loves to live so also as life. Prior to admission, he believes that
he is in good health and that he has good quality of resistance. He
does exercises like biking every morning for almost 30 minutes and
eating healthy foods in maintaining a healthy lifestyle. He has noknown allergies so far. And when he had illness, he drinks medicine
like Bioflu and Biogesic. He said that taking those medicines are
helpful enough to treat his illness. R.R.A. does not use any herbal
medicines since it is not available in their place. He started smokingsince high school at the age of 13, according to him it is because of
peer pressure. Since then, he can consumed 1 pack of cigarette per
day. He also said that he can drink a case of alcohol by himself. He
was circumcised at the age of 12 years old when he was on Grade 6.
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Upon hospitalization, patient still perceiveshealth as an important part of life. He is awarethat drinking alcohol and smoking cigarettes isnot a healthy lifestyle, but since he was
influenced and addicted with it, he couldnt resistfrom taking such. He is now taking too manymedications to keep him healthy and to preventfurther complications on his illness. He said that
he wants to go home to do those past activitiesthat he is doing before and is complaining offeeling of boredom.
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II. Nutritional Metabolic Pattern
The patient usually eats rice, vegetables, meat and sea foods.
Prior to admission the last food that he ate was sardines and 2cups of rice. He loves to eat and his favorite dishes are
sinampalukang manok, calderetang spare ribs and pancit
palabok. He also stated that he ate 6 meals and drinks 6 liters
of water a day. He does not take any supplements or vitamins.
He used to weigh 65kgs. before but now that he was
hospitalized he thinks that he lost some of his weight. He
does not experience any discomfort or problems in
swallowing. Patient R.R.A is ectomorph. He was on NPO for 3
and half days and after that he was ordered to have a cleardiet. He only got his nutrients from the dextrose that was put
in to him.
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III. Elimination Pattern
Prior to hospitalization, R.R.A. usually defecates every morning witha firm, brownish in color feces. And has no problem in controlling
his bowel and has no discomfort in defecating. He eliminates urine
several times a day, usually yellowish in color depending on the
amount of fluids he takes. Has no problem in controlling and
eliminating his urine. Does not lose bowels and urine when he does
not want to. Has no excess perspiration and body odor. There is no
body cavity drainage attached to the patient. The day before his
admission, he experienced passing bloody stools.
Upon hospitalization, patient R.R.A. has difficulty in passing stoolsthats why he was ordered to be given laxatives and suppositories
to help him defecate. He only defecated 2 times since admission.
Because the client is in NPO so we can expect that he has a hard
stool.
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IV. Activity Exercise Pattern
According to patient R.R.A. he has sufficientenergy enough for his desired activities athome and at his work. He is a very active
person back then that he used to bike andwork for his parents. His means of exercise isthrough biking for almost 30 minutes everyday. He spends his spare time by staying with
his friends house and chatting with them. Heis also fond of drinking alcohol and smokingcigarettes with his friends.
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KATZ Index
Act iv i t ies Independence = 1 pt . Dependence = 0 pt .
Bathing 1
Dressing 1
Toileting 1
Transferring 1
Continence 1
Feeding 1
Total Points: 6
The table above shows that patient can do most of the activities of daily
living. He is independent to his caregiver or significant other when it comes
to moving or doing simple activities such as transferring, toileting and
feeding before and during hospitalization.
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V. SleepRest Pattern
Patient R.R.A said that he usually goes to sleep at 12midnight and wakes up at 7am and he feels rested andready for daily activities. According to him he does nothave any problems in sleeping. He does not snore. He
also added that he frequently had dreamt of being fell.He sometimes wakes up at dawn just to void.
Upon hospitalization the patient said that he is notgetting his usual sleeping pattern like before. Thepatient cant sleep well because of the humid
temperature at the hospital and also he is unfamiliarwith his surroundings that is why he feels not fullyrested in the morning. He does not use any sleepingaids to promote sleep.
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VI. Cognitive Perceptual Pattern
The patient complains of having pricking pain in hisright abdomen. That occurs after he had drunk againalcohol that made his stomach bloated. He scored it 8out of 10 and rests seems to help to alleviate the pain.
As signs of aging, he is wearing eye glasses because hecouldnt read words and phrases 12 inches away fromhim. He doesnt have problems in hearing, smellingand his sense of touch. He said that he has a goodmemory with regards with dates. And is aware of the
current events and issues in his country. He has noproblems in concentration. And has no learningdisability. He learns best through personal experiences.
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VII. Self- Perception Pattern
As stated by the patient he is a joyful person he lovesto make people laugh. And most of the time feels goodabout his self. His vocabulary in life is that if he thinkshe can do it he will probably make more than of it.
When he was a child he likes to be outside their houseand play with other children. He said that he is kindand approachable person. When he got problems hetried to calm his self and he thinks optimistically. Hesaid that as soon as he get discharge he will find a work
and will spends most of his time with his family notwith his friends. He thinks that sometimes he get alittle bit odd with people but he assure that he will notharm any of his family.
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VIII. Role Relationship Pattern
According to the patient his family was always mad at himbecause of his consistent vice of drinking alcohol. He also added
that he take drugs before. He lived with his mother and father
because he is still single. And they have a nuclear type of a
family. He is not married yet and is not planning to have
marriage. In his hospitalization right now, her sister and other
siblings are the ones managing the expenses in the hospital.
When he has problems he asks for the help of his older sister
and his friends. He solved his and their familys problem by
talking over with it. He thinks that his mother doesnt like himat all. The client wanted to go home because he feels lonely and
he wished to see his parents. He thinks that he cant court any
girls anymore because of his age. He does not feel isolated from
his neighborhood but misjudge because of his vices.
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IX. Coping Stress Pattern
R.R.A. has someone with him whom he cantalk to but there are times that he just wantedto be alone to think. He likes to help his family
in terms of financial needs. He said that nowhis family is always there by his side tosupport him. The patient never thought ofcommitting suicide because he enjoys life.
When he is stressed he just finds a placewhere he can think and also eat the foods thathe likes.
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X. Value Belief Pattern
Generally, patient gets those things he wantssince he is earning money by himself. Mostimportant part of his life is his parents. The
patient is a Catholic. According to him when hegot sick he always prays but after he recovered hewill not do the usual thing he do when he is sickand he admits that. Now he realized the
importance of having God in our life and weshould always have a strong faith to God. Atpresent he prays before going to sleep.
PHYSICAL
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PHYSICALEXAMINATION
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DI GNOSTIC TEST
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Patient Initial: R.R.A
Age: 49 y/o
Diagnosis: Liver Cirrhosis, Acute Anemia 2oto UGIB
HEMATOLOGY REPORT
EXAM DATE; 3/09/2013
3:05 pmTEST RESULT UNIT REFERENCES
WHITE BLOOD CELLS
RED BLOOD CELLS
HEMOGLOBIN
HEMATOCRIT
MCV
MCH
MCHC
PLATELET
Neutrophil (%)
Lymphocytes (%)
Monocytes (%)
Eosinophils (%)
Basophils (%)
RDM CV
MPV
9.10
2.37
75.0
20.9
88.2
31.6
35.9152
73.4
16.0
8.0
2.4
0.2
15.1
10.3
10^3/uL
10^6/uL
G/L
%
fL
pg
g/dL10^3/uL
%
%
%
%
%
%
fL
5.010.0
M 4.7-6.1 F 4.05.5
M 135180 F 120;.160
M 42.052.0 F37.047.0
M 80 -94 F 81-99
27.031.0
33.037.0150450
50.070.0
25.040.0
3.011.0
1.04.0
0.01.0
11.514.5
7.211.1
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March 10
TIME RECEIVED: 5:00 AM
TIME FINISHED: 9:30 AMCLINICAL CHEMISTRY
COBAS INTEGRA 400 PLUS Generated Result
Test Result Reference Ranges
GLUCOSE (FASTING) 5.42 4.115.89 mmol/L
CHOLESTEROL 2.67 Up to 5.2 mmol/L
TRIGLYCERIDES 0.25 Up to 2.3 mmol/L
HDL 0.986 Mgreater than 1.45
mmol/L
Fgreater than 1.68mmol/L
LDL 1.6 Less than 2.59 mmol/L
VLDL 0.11 Less than 1.04 mmo/L
ALK. PHOS. 157.4 M40 -129 U/LF35104 U/L
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EXAM DATE; 3/11/2013
11: 36 amTEST RESULT UNIT REFERENCES
WHITE BLOOD CELLSRED BLOOD CELLS
HEMOGLOBIN
HEMATOCRIT
MCV
MCH
MCHC
PLATELET
Neutrophil (%)
Lymphocytes (%)
Monocytes (%)
Eosinophils (%)
Basophils (%)
RDM CVMPV
RETICULOCYTE
COUNT
ERTHROCYTE
SEDIMENTATION
RATE
CLOTTING TIMEBLEDDING TIME
4.013.11
98.0
29.0
93.2
31.5
33.8
228
62.9
23.2
9.0
4.7
0.2
16.110.0
10^3/uL10^6/uL
G/L
%
fL
pg
g/dL
10^3/uL
%
%
%
%
%
%fL
%
MM/HR
MIN
MIN
5.010.0M 4.7-6.1 F 4.05.5
M 135180 F 120160
M 42.052.0 F37.0
47.0
M 80 -94 F 81-99
27.031.0
33.037.0
150450
50.070.0
25.040.0
3.011.0
1.04.0
0.01.011.514.5
7.211.1
ADULT 1-2 INFANT 4-8
M 010 F 0-20
24
24
CLINICAL CHEMISTRY
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COBAS INTEGRA 400 PLUS Generated ResultaA
Test Result Reference Ranges
GLUCOSE 5.21 4.115.89 mmol/L
CHOLESTEROL 3.21 Up to 5.2 mmol/L
TRIGLYCERIDES 0.41 Up to 2.3 mmol/LHDL 1.089 Mgreater than 1.45 mmol/L
Fgreater than 1.68 mmol/L
LDL 1.9 Less than 2.59 mmol/L
VLDL 0.19 Less than 1.04 mmo/L
SGOT (AST) 70.2 Mup to 40 U/L
Fup to 32 U/L
SGPT (ALT) 33.0 Mup to 41 U/L
Fup to 33 U/L
ALK. PHOS. 131.4 M40 -129 U/L
F35104 U/L
T. PROTEIN 66.60 6483 g/LALBUMIN 51.23 3552 g/L
GLOBULIN 15.41 2335 g/L
A/G Ratio 3.3 1.12.5 g/L
T. BILIRUBIN 12.70 Less than 17.0 umol/L
D. BILIRUBIN 6.64 03.4 umol/LIND. BILIRUBIN 6.02 1.710.1 umol/L
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DATE: MARCH 13 2013
TIME RECEIVED: 6AM
TIME RELEASED: 7:40AM
CLINICAL CHEMISTRY
COBAS INTEGRA 400 PLUS Generated Result
Test Result Reference Range
T. PROTEIN 27.3 6483 g/L
ALBUMIN 6.49 3552 g/L
GLOBULIN 20.81 2335 g/L
A/G Ratio 0.31 1.12.5 g/L
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N TOMY andPHYSIOLOGY
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P THOPHYSIOLOGY
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DRUG STUDY
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NURSING CARE PLAN
Prioritization of the problem
Actual problem
1. Abdominal Pain
2. Elevated blood pressure
3. Poor hygiene
4. Disturbed sleep pattern
5. Impaired Skin Integrity
6. Impaired Dentition
Potential Problem
1. Risk for Imbalanced Nutrition: less than body requirements
2. Risk for bleeding
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NURISNG CARE PLAN: Acute PainAssessment Diagnosis Planning
Subjective Data:
Sumasakit yung bandang dito ko.
Kumikirot na parang tumitibok
ganun.
Objective Data:
Vital signs of:
T: 36.9
PR: 78
RR: 20
BP: 160/100
(+) mild pricking pain @ Right upper
quadrant of abdomen
Pain scale of 4
out of 10 with 10 as severely painful.
Hard to palpate abdomen
(+) facial grimace
(+) restless
Acute pain
related to
splenomegaly
and liver
inflammation as
evidenced by
hard to palapate
abdomen, mild
pricking pain @
right upper
quadrant of
abdomen,
restlessness and
irritability
secondary to
liver cirrhosis.
Short term:
After 2 hours of nursing intervention,
the patient should have decreased
level of pain from 4/10 to at least 1
2/10, and should have lesser signs of
irritability, facial grimace and
restlessness.
Long Term:
After nursing intervention, the patient
should have understood the
techniques and methods that can be
done in order to reduce pain, and to
maintain and practice the relaxation
methods used at times of discomfort.
Intervention Rationale Evaluation
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te e t o at o a e a uat o
Independent Nursing intervention:
1. Introduced self and established rapport
with the patient.
2. Monitored and recorded vital signs
3. Assessed level of pain, location, andcharacteristic.
4. Positioned the patient in a comfortable
position
5. Instructed the patient to do deep
breathing exercises when in pain.
6. Rendered health teaching about some of
the relaxation methods that can be used
to lessen pain.
Dependent Nursing intervention:
1. Assisted during giving of medications for
pain.
Collaborated Nursing intervention
1. Advised the guardian to help the patient
at times of pain and to always be at bed
side.
2. Instructed the guardian to immediately
report any untoward signs and symptoms.
- To gain trust from the patient
- For base line data.
- Assessment of pain for
additional data
- To promote comfort and lessen
pain sensation.
- In order for the patient not to
feel too much pain at times of
sensation.
- For the patient to know what to
do at times of pain, and to
control pain sensation.
- To lessen pain and promote pain
relief to the patient.
- Presence and care of a guardiancan help lessen the pain felt by
the patient.
- To prevent other complications
and to respond immediately to
the problem before it worsens.
Goal Met
After nursing
intervention, the
patients pain scale
lowered from 4 out
of 10 to 2 out of 10.
NURISNG CARE PLAN El d
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NURISNG CARE PLAN: Elevated
Blood Pressure
Assessment Diagnosis PlanningSubjective Data:
Wala akong nararamdaman, sadyang mataas
lang talaga BP ko.
Objective Data:
Blood pressure recordings:03-12-13 (PM)
3:00: 160/100
5:00: 150/90
03-13-13 (PM)
3:00: 140/90
5:00: 130/80
(+) mild, pricking pain @ right upper
abdomen
Pain scale of 4 out of 10 with 10 as highest.
Medication of Furosemide for management
of hypertension.
Decreased cardiac
output related to
liver inflammation
and pain as
evidenced byelevated blood
pressure of 160/100
and pain at right
upper abdomen
secondary to livercirrhosis.
Short term:
After 2 hours of nursing
intervention, the patients
blood pressure should have
decreased from 160/100 toat least 130/90 mmHg.
Long Term:
After nursing intervention,
thepatientsblood pressure
should have normalizedfrom 150/100 to 120/80,
and should have
maintained normal blood
pressure range.
I ntervention Rationale Goal Met
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I ntervention Rationale Goal MetIndependent Nursing intervention:
1. Established rapport with the
patient.
2. Monitored and recorded vitalsigns
3. Monitored blood pressure every 2
hours.
4. Provided comfort to the patient
5. Advised patient to rest.6. Instructed patient to sit down and
avoid walking and getting up from
the bed frequently.
Collaborated Nursing intervention
1. Advised guardians to removestressors and any factors that may
affect the patients blood pressure
range.
2. Instructed the guardians to report
any untoward signs and
symptoms.
- To gain trust from the
patient
- For baseline data- For further
assessment of px
condition.
- To promote relief and
comfort- To lessen the factors
that may contribute to
the elevation of blood
pressure.
- To prevent further
complications and to
respond to the
problem immediately.
After nursing
intervention, the
patients bloodpressure decreased
from 160/100 to
130/80 mmHg.
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NURISNG CARE PLAN: Poor HygieneAssessment Diagnosis Planning
Subjective Data:Limang na araw na akong
di naliligo, ambaho ko na.
Objective Data:
(+) dry skin
(+) foul breath odor(+) dirty nails on feet
(+) oily hair
(+)tooth cavity on left
incisor
Dirty clothesUntidy appearance
Unfixed hair
Yellowish teeth
Self care deficit related to poorpersonal hygiene as evidenced
by foul breath odor, untidy
appearance, oily hair, and
infrequent bathing secondary
to liver cirrhosis.
Short term:After 1 hour of nursing
intervention, the patient should
look tidy and pleasing. He should
have taken a bath, teeth should be
brushed and hair should be fixed.Long Term:
After nursing intervention, the
patient should have maintained a
tidy outlook with a pleasing
personality. Proper hygienetechniques should be maintained
and practiced even after
hospitalization.
I ntervention Rationale Evaluation
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I ntervention Rationale Evaluation
Independent Nursing
intervention:
1. Established rapport with the
patient and NPI done.2. Assessed the patients
appearance and hygiene.
3. Rendered Physical
examination
4. Rendered patient health
teaching about proper hygieneand its importance.
5. Advised patient to take regular
baths and to brush teeth for at
least 3x a day.
Collaborated Nursing
intervention
1. Advised the guardian to
always remind and encourage
the patient to take a bath daily
and brush teeth.
- To gain trust from the patient
- To gather more information
and data to assess hiscondition.
- For base line and additional
data
- To increase patients
knowledge about proper
hygiene and for him to knowthe techniques to keep himself
tidy.
- To keep self tidy and clean,
and to have a good personal
hygiene.
- To maintain patient hygiene
and to remind him to keep hi
Goal Met
After nursing intervention, the
patient took a bath and tidied
himself.
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NURISNG CARE PLAN: Disturbed Sleep
PatternAssessment Diagnosis Planning
Subjective Data:
hindi ako nakakatulog ng
maayos dito. Namamahay kasi
ako eh.Objective Data:
Sleep hours before
hospitalization: 78 hours
Sleep hours after
hospitalization: at least 34
hours
Interrupted sleep at night
(+) restlessness
(+) irritability
Disturbed sleep pattern
related to
Unfamiliar sleep
surroundings and lightingas evidenced by
interrupted sleep hours of
at least 3 hours,
restlessness, and
irritability.
Short term:
After 1 hour of nursing
intervention, the patients
sleep hours should increasefrom 34 hours to at least
8 hours. Signs of irritability
and restlessness should be
lessened.
Long Term:
After nursing intervention,
the patient should have a
regular sleeping pattern and
no signs of restlessness and
irritability.
Interventiona Rationale Evaluation
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Interventiona Rationale Evaluation
Independent Nursing intervention:
1. Established rapport with the
patient.2. Rendered physical examination.
3. Interviewed the patient regarding
his sleeping habits and pattern.
4. Provided comfort to the patient.
5. Suggested diversional activities
before sleep such as listening to
classical music or reading a book.
6. Advised patient to use eye cover if
the room is too bright, and to pray
before sleeping.
Collaborated Nursing intervention
1. Advised guardian to keep the
surrounding quiet and peaceful.
- To gain trust from the
patient- For base line data
- To gather more
information regarding
the patients concern
- To promote relief to
patient
- To help the patient to
sleep, and to stimulate
eyes in order for the
patient to have
continuous sleep.
- To help the patient to
sleep properly.
Goal Partially Met
After nursing
intervention, thepatient had
decreased signs of
restlessness and
irritability but was
not able to sleep
continuously for 8
hours.
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NURISNG CARE PLAN: Impaired Skin
Integrity
Assessment Diagnosis Planning
Subjective Data:
May sugat ako sa ulo
tsaka marami akong
peklat dahil na rin sapagbibisikleta
Objective Data:
(+) wound @ left parietal
side of the head
(+) dry skin
Poor skin turgor
Thin in appearance
Inadequate food intake
6 glasses of water a day
Impaired skin integrity related
to presence of wound and
imbalanced nutritional state as
evidenced by wound at leftparietal side of the head, dry
skin, poor skin turgor, and
inadequate food intake,
secondary to liver cirrhosis.
Short term:
After nursing
intervention, the patients
skin should be moist andwound should be cleaned
and disinfected.
Long Term:
After nursing
intervention, the patient
should have maintained
integrity of skin by
keeping it moist and
cleaned daily.
I ntervention Rationale Evaluation
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Independent Nursing intervention:
1. Established rapport with the patient
2. Rendered physical examination
3. Assessed patients wound on thehead
4. Performed wound care to the
patient and provided frequent skin
care
5. Informed and demonstrated the
proper wound dressing to the
patient and guardians
6. Advised patient to avoid use of soap
and alcohol based lotions.
7. Advised patient to take a bath daily.
Collaborated Nursing intervention
1. Instructed the guardian to perform
wound care and assess skin of the
patient from time to time.
- To gain trust from the patient
- For base line data
- To gather more information anddata to assess his condition
- To prevent infection
- To ensure continuity of care
- To keep the skin moist and
hydrated
- To ensure continuity of care and
to prevent further complications.
Goal Met
After nursing
intervention, the
patients skinappeared moist
and the wound
was cleaned.
The patient
understood and
complied with
the health
teaching of the
student nurse.
NURISNG CARE PLAN: Impaired
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NURISNG CARE PLAN: ImpairedDentition
Assessment Diagnosis Planning
Subjective Data:
Kulang na talaga yung ngipin ko.
Di na ako nagpupustiso kasi
nawala ko. Pero dati may pustiso
ako.
Objective Data:
Incomplete number of teeth: 10
(+) tooth cavity: left lower incisor
(+) foul breath odor
Yellowish teeth
Not frequent tooth brushing: 4
times a week.
Excessive Alcohol intake: 12
cases per session
Impaired dentition
related to ineffective oral
hygiene and dietary
habits as evidenced by
halitosis, teeth
discoloration, dental
carries, and non frequent
tooth brushing.
Short term:
After 1 hour of nursing
intervention the patient should
have no foul breath odor and
should have white teeth.
Long Term:
After nursing intervention, the
patient should have continued the
use of dentures and should have a
regular check-up with the dentist.
Intervention Rationale Evaluation
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Intervention Rationale Evaluation
Independent Nursing intervention:
1. Established rapport with the
patient.
2. Rendered physical examination
3. Assessed the patients dentition,
teeth, and mouth.
4. Advised patient to brush teeth for
at least 3 times daily.
5. Advised patient to continue use of
dentures and to visit a dentist for
every 6 months.
Collaborated Nursing intervention
1. Advised patient for referral to a
dentist for complete checkup
and for replacement of dentures.
- To gain trust from the patient
- For base line and additional data- To gather more information and
data to assess his condition
- To keep teeth healthy and clean.
- To have a proper consultation
about dentition and to prevent
further complications and
cavities.
- For continuity of care and for
further assessment of the patients
condition.
Goal partially Met
After nursing intervention,
the patient does not have
foul breath odor but the
teeth is still yellowish.
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I ntervention Rationale Evaluation
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I ntervention Rationale Evaluation
Independent Nursing
intervention:
- Established rapport with the
patient- Rendered physical
examination.
- Maintained patients clear
liquid diet.
- Listened to the patients
verbalization of concerns- Explained the importance of
maintaining the diet prescribed
to the patient.
- Encouraged the patient to
endure diet until his condition
was already stabilized.
Collaborated Nursing
intervention
- Advised guardian not to feed
the patient solid food unless
the doctors diet order was
changed.
- To gain trust from the patient.
- For base line data
- As prescribed by the physician
- To promote comfort and to provide
an outlet for the patient.- To provide knowledge and
additional information that the
patient needs.
- To prevent further complication and
problems to the patient.
Goal Met
After nursing intervention,
the patient understood the
importance of propernutrition and its risks.
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NURISNG CARE PLAN: Risk for
Bleeding
Assessment Diagnosis Planning
Objective Data:
With history of upper gastro intestinal
bleeding
With history ofHematochezia (blood in stool) prior to
admission
Medications of:
Vitamin K
Tranexamic acid
For blood clottingLaboratory result before blood
transfusion:
Platelet count of 152 (normal 150
450) : near to minimal range
Blood transfusion of Packed RBC on
March 10, 2013
Risk for bleeding related to
scarring of upper gastro
intestinal tract due to liver
cirrhosis.
Short term:
After 1 hour of nursing intervention,
the patient should be free from signs
of bleeding.Long Term:
After nursing intervention, the patient
should not have any reports of
recurrent bleedings.
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PROGRESS NOTESXIV. PROGRESS NOTESPatient: R. R. A.
Diagnosis: Liver Cirrhosis, Acute Anemia secondary to UGIB
On the first day of our duty that is on March 11, 2013 Monday in GEAMH (General
Emilio Aguinaldo Medical Hospital), we handle our client RRA in the medical ward with the
diagnosis of Liver Cirrhosis, Acute Anemia, secondary to (UGIB) upper gastrointestinalbleeding. We received the patient awake in bed in a sitting position with IVF PNSS 1L level
300cc@ Left metacarpal vein regulated @ 31-32gtts/min. He is conversant and ambulatory
upon the interview, but he feels irritable on that time because of hot atmosphere in the
medical ward it makes him uncomfortable feelings. After assessing the patient condition and
NPI is done, we take the initial vitals sign of the patient. There are all-normal in v/s except
his BP it increase in 140/90. We immediately refer to the staff nurse about the increase BP ofour patient. In addition, to alleviate the uncomfortable feelings of our clients, we established
rapport to the patient and provided therapeutic communication. We also encouraged the
patient to verbalize his feelings to relieve his uncomfortable feelings. When the patient felt
relax and rested, we do the physical assessment thoroughly.
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On the second day our duty that is on March 12, 2013
Tuesday, after the endorsement we received our patient awake
on bed in a supine position with an IVF PNSS 1L withincorporated with B-complex at the level of 250cc regulated at
31-32gtts/min, he is conscious and coherent. Again, we take
the initial vital signs of our patient his BP is 130/80, which is
lower than on the first day. We do again nursing patientinteraction. Then, during the interview, he told as that he feels
abandoned, and he missed her parents very much. We advised
him to do some diversional activities such as, talking with the
other patients and listening to music. We also encouraged him
to relax and avoid thinking of stressful things to lessen his
loneliness. After a while, one of his relative visited him in the
medical ward, our patient feel better and happy.
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On the third day of our duty that is onMarch 13, 2013 Wednesday, we continued our
health teaching to our patient. We taught andremind them about the prevention ofcomplications that can be accomplished bytreating his liver cirrhosis secondary to upper
gastrointestinal bleeding through taken themedication prescribed by his doctor. We alsoadvised to stop smoking, do exercise as needed
or resuming activities of daily living that can stillbe done by the patient, and the reduction in saltand alcohol intake.
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MEDICATION The patient advised to follow and take the
prescribed medication regimen needed to the
prompt recovery and effective treatment.
Teachings and giving information about
medicines adverse effects and its side effects
are also put into practiced. The following
medications were prescribed as follows:
Lanexamic acid
Rebamibide
Furosemide
Omeprazole
Morlam forte
Vit.K
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ENVIRONMENT/ EXERCISE Advised the patient to have a safety environment
and avoid hazardous places to keep away from
further injury or accident. Instructed the patient to
do exercises and relaxation technique as
tolerated such as walking, yoga and meditation.
The patient will have no restrictions to physical
activities; however, the patient should pay
attention to their body in reaction to certainactivities. Gradually increase activities at a
comfortable and individual pace.
TREATMENT Instructed the patient to comply the long-term
treatment for his condition and to monitor the
possible sign and symptoms of the disease.
HYGIENE Instructed the patient to do proper hygiene such as,
take a bath every day, trimming the nails, changing
clothes everyday and brushing his teeth after eating.
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OPD The patient instructed to have his follow-up check-up with a
hepatologist or gastroenterologist in the OPD for his quick
recovery.
DIET Encouraged patient to avoid fatty/oily foods; avoid sour
food and drinks.
Avoid spicy foods otherwise nothing by mouth if with
persistent abdominal pain.
Encouraged patient to increase fluid intake.
Encouraged patient to eat foods rich in vitamins and
nutritious foods.
Recommending dietary changes of decreased/avoiding fat
intake is prudent; this may decrease the incidence of
gastrointestinal bleeding.
Since maximum liver function is essential for proper bile
formation, it is also important to reduce chemical stress
upon the liver (remember, the liver produces the bile
which must have proper levels of cholesterol, bile acids
and lecithin and synthetic chemicals are well known for
weakening liver function).
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SPIRITUAL CARE Advised the patient to read spiritual and uplifting books. Think about what
you read, and find out how you can use the information in your life
Meditate for at least 15 minutes every day.
Learn to make your mind quiet through concentration exercises and
meditation.
Acknowledge the fact that you are a spirit with a physical body, not a
physical body with a spirit. If you can really accept this idea, it will change
your attitude towards many things in your life.
Look often into yourself and into your mind, and try to find out what is it that
makes you feel conscious and alive.
Advised the patient to think positive. If you find yourself thinking negatively,
immediately switch to thinking positively. Be in control of what enters your
mind. Open the door for the positive and close it for the negative.
Develop the happiness habit, by always looking at the bright side of life and
endeavoring to be happy. Happiness comes from within. Do not let your
outer circumstances decide your happiness for you.
Exercise often your will power and decision making ability. This strengthens
you and gives you control over your mind.
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