Category Archives: Cardio, GI & Respi
NURSING DIAGNOSIS: Knowledge Deficit
- Lack of exposure/recall; information misinterpretation
- Unfamiliarity with information resources
- Questions; request for information, statement of misconception
- Inaccurate follow-through of instructions/development of preventable complications
- Verbalize understanding of disease process/prognosis, potential complications.
- Correlate symptoms with causative factors.
- Identify/initiate necessary lifestyle changes and participate in care.
NURSING DIAGNOSIS: Self-Esteem/Body Image disturbed
- Biophysical changes/altered physical appearance
- Uncertainty of prognosis, changes in role function
- Personal vulnerability
- Self-destructive behavior (alcohol-induced disease)
- Verbalization of change/restriction in lifestyle
- Fear of rejection or reaction by others
- Negative feelings about body/abilities
- Feelings of helplessness, hopelessness, or powerlessness
- Verbalize understanding of changes and acceptance of self in the present situation.
- Identify feelings and methods for coping with negative perception of self.
NURSING DIAGNOSIS: Injury, risk for [hemorrhage]
- Abnormal blood profile; altered clotting factors (decreased production of prothrombin, fibrinogen, and factors VIII, IX, and X; impaired vitamin Kabsorption; and release of thromboplastin)
- Portal hypertension, development of esophageal varices
- Maintain homestasis with absence of bleeding
- Demonstrate behaviors to reduce risk of bleeding.
NURSING DIAGNOSIS: Breathing Pattern, risk for ineffective
- Intra-abdominal fluid collection (ascites)
- Decreased lung expansion, accumulated secretions
- Decreased energy, fatigue
- Maintain effective respiratory pattern; be free of dyspnea and cyanosis, with ABGs and vital capacity within acceptable range.
NURSING DIAGNOSIS: Skin Integrity, risk for impaired
- Altered circulation/metabolic state
- Accumulation of bile salts in skin
- Poor skin turgor, skeletal prominence, presence of edema, ascites
- Maintain skin integrity.
- Identify individual risk factors and demonstrate behaviors/techniques to prevent skin breakdown.
NURSING DIAGNOSIS: Fluid Volume excess
- Compromised regulatory mechanism (e.g., syndrome of inappropriate antidiuretic hormone [SIADH], decreased plasma proteins, malnutrition)
- Excess sodium/fluid intake
- 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
- Demonstrate stabilized fluid volume, with balanced I&O, stable weight, vital signs within patient’s normal range, and absence of edema.
Nursing Diagnosis: Nutrition: imbalanced, less than body requirements
- Inadequate diet; inability to process/digest nutrients
- Anorexia, nausea/vomiting, indigestion, early satiety (ascites)
- Abnormal bowel function
- Weight loss
- Changes in bowel sounds and function
- Poor muscle tone/wasting
- Imbalances in nutritional studies
- Demonstrate progressive weight gain toward goal with patient-appropriate normalization of laboratory values.
- Experience no further signs of malnutrition.
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.
8 Liver Cirrhosis Nursing Care Plans
- Imbalanced Nutrition — Liver Cirrhosis
- Excess Fluid Volume — Liver Cirrhosis
- Impaired Skin Integrity — Liver Cirrhosis
- Ineffective Breathing Pattern — Liver Cirrhosis
- Risk for Injury — Liver Cirrhosis
- Risk for Acute Confusion — Liver Cirrhosis
- Disturbed Body Image/Self-Esteem — Liver Cirrhosis
- Knowledge Deficit — Liver Cirrhosis
Image Courtesy: http://nurseslabs.com/
- Altered myocardial contractility/inotropic changes
- Alterations in rate, rhythm, electrical conduction
- Structural changes (e.g., valvular defects, ventricular aneurysm)
Possibly evidenced by
- Increased heart rate (tachycardia), dysrhythmias, ECG changes
- Changes in BP (hypotension/hypertension)
- Extra heart sounds (S3, S4)
- Decreased urine output
- Diminished peripheral pulses
- Cool, ashen skin; diaphoresis
- Orthopnea, crackles, JVD, liver engorgement, edema
- Chest pain