N360 Concept Map Care Plan Diane Nichols Professor Rosado

o Desired Outcomes 1. Fluid Volume Excess: The patient will experience a decrease in ascites as evidenced by decreased abdominal girth. o o o o o o o o o o o o o o o o o o o o o o o o o o o o Interventions 1. Fluid Volume Excess: Assess for presence of ascites Strict I & O & daily weights Administer lactulose, diuretics (cautiously) Paracentesis as needed or continuous peritoneal drainage 2. Ineffective Breathing Pattern: Assess resp. rate, rhythm, depth, lungs, O2 saturation levels & ABGs Position patient for comfort & ease of breathing NC for O2 administration to keep sats above 90% Sxn scheduled & prn by RT 3. Infection Assess for S & S of infection, LOC, BUN, neutrophils & ABGs Monitor temp, HR & BP Administer IV antibiotics 4. Impaired Mobility Assess patients ability to perform ADLs safely & ROM to all joints Evaluate safety of environment Perform active or passive ROM to all extremities Provide a safe environment; bed locked & low, personal items within reach, assist with ADLs, & a sitter at bedside 5. Imbalanced Nutrition Assess for changes in body weight & muscle mass Document intake Monitor coagulopathies, potassium & albumin/protein levels Provide TPN as needed/tolerated 6. Acute Confusion Assess LOC, degree of impairment Administer lactulose, titrate to 3-4 BMs per day Provide a safe/calm environment 7. Elimination Assess elimination pattern, amt & frequency Monitor BUN Administer lactulose Q2H, bisocodyl PRN, furosemide Maintain strict I & O (use foley catheter for accurate UOP measurement & colostomy to R groin for peritoneal drainage) 8. Ineffective Health Maintenance Assess patient & familys ability to maintain health Assist patient & family with referrals & teaching materials

2. Ineffective Breathing Pattern: Patient will maintain effective breathing pattern as evidenced by a normal breathing rate in a relaxed manner with an O2 sat above 90%.

3. Infection The patient will be free of infection as evidenced by normal temp, WBC count & normal LOC. 4. Impaired Mobility Patient is free of complications of immobility as evidenced by clear lungs, absence of thrombophlebitis, intact skin & normal elimination pattern.

5. Imbalanced Nutrition Patient achieves adequate nutrient intake as evidenced by normalized coagulopathies, potassium & albumin/protein levels.

6. Acute Confusion Patient will remain safe and free from harm.

7. Elimination Patient will maintain UOP levels >30mL/hr & 3-5 bowel movements daily.

8. Ineffective Health Maintenance Patient demonstrates effective health maintenance behaviors.

N360 Concept Map Care Plan Diane Nichols Professor Rosado

Evaluation Fluid volume excess goals have not yet been met. Patient has a foley catheter to measure UOP and a colostomy bag to continuously drain peritoneal fluid. Abdomen remains distended due to ongoing ascites, TPN discontinued due to increasing fluid retention and low UOP. NS at 75 mL/hr IV, lactulose titrated to 3-4 BM/day (currently at 20g/30ml Q2H, even hrs). Ineffective breathing pattern goals have been met. Although patient respiration rate is 22 on 2L NC, saturation is at 94% and patient breathing pattern remains relaxed. Suctioning as needed. ABGs currently remain within normal limits. Patient HOB at or above 30 while in bed, up to chair as tolerated. Infection goals have not been met. Patient VS normal, 98.1F, P 99, BP 126/84, RR 22, 94% O2 saturation. Patient remains confused with episodes of improving clarity increasing with lactulose administration. BUN 33 on 3/31, down to 25 on 4/1. Neutrophils still elevated at 75.0, abs neutrophils at 6.52 on 4/1. Impaired mobility goals have been met. Patient lungs are clear, skin remains intact and elimination is improved with more frequent BMs. Patient able to tolerate active ROM, out of bed to chair and PT. Imbalanced nutrition goals have not been met. Patient remains NPO except for meds due to previous attempt at PO intake resulted in respiratory distress due to aspiration pneumonia on 3/20. Coagulopathies, potassium and albumin levels remain abnormal, mostly due to liver failure and inability to intake nutrients, PO or TPN. Acute confusion goals have been met. Patient has remained safe and free from harm. With increasing lactulose administration patient experiences increasing moments of clarity and ability to communicate. Elimination goals have been partially met. UOP remains low but lactulose has helped with increasing numbers of BMs. BUN down to 25 from 33. Ineffective health maintenance goals have not been met. Patient remains unable to care for herself but family communicates desire to do whatever they can to help and a willingness to learn what they can in order to assist and care for patient. Discharge Plan Patient remains unstable at this time and not ready for discharge. Patient diagnosis of liver failure due to alcohol abuse excludes her from possible liver transplant. Ongoing acute confusion makes patient teaching difficult and patient wishes in regard to treatment are unknown at this time. Once stable, patient can be informed of her illness, prognosis and options. Patients family teaching is ongoing and they remain willing to take care of her. Patient to be released home with parents and sister. Follow up care should be strictly adhered to as well as ingesting no alcohol or alcohol containing products (patient consumed mouthwash with 26% alcohol to hide alco hol intake from family). Depending upon patients response to treatment and prognosis hospice may be an option to explore.

N360 Concept Map Care Plan Diane Nichols Professor Rosado

Resources Gulanick, M., & Myers, J. (2011). Nursing care plans: diagnoses interventions, and outcomes. (7th ed.). PA: Mosby. Kee, J. (2013). Handbook of laboratory & diagnostic tests with nursing implications. (7 th ed.). New Jersey: Pearson.