ASKEP SIROSIS HEPATIS

TINA HANDAYANI NASUTION

Activity intolerance related to fatigue, lethargy, and malaise

Expected Outcomes
Exhibits increased
interest in activities and
events.
Participates in
activities and gradually
increases exercise within
physical
limits.
Reports increased
strength and well-being.
Reports absence of
abdominal pain and
discomfort.
Plans activities to allow
ample periods of rest.
Takes vitamins as
prescribed.

Nursing
Interventions

Rationale

1. Assess level of activity

tolerance and degree of
fatigue, lethargy, and
malaise when performing
routine activities of daily
living.
2. Assist with activities and
hygiene when fatigued.
3. Encourage rest when
fatigued or when abdominal
pain or discomfort occurs.
4. Assist with selection and
pacing of desired activities
and exercise.
5. Provide diet high in
carbohydrates with protein
intake consistent with liver
function.
6. Administer supplemental
vitamins(A, B complex, C,
and K).

1. Provides baseline for

further assessment and
criteria for assessment
of
effectiveness of
interventions.
2. Promotes exercise and
hygiene within patients
level of tolerance.
3. Conserves energy and
protects theliver.
4. Stimulates patients
interest in selected
activities.
5. Provides calories for
energy and protein for
healing.
6. Provides additional
nutrients.

Imbalanced nutrition: less than body requirements, related to abdominal distention, discomfort and anorexia
Expected Outcomes

Exhibits improved nutritional status

by increased weight (without uid
retention) and improved laboratory
data.
States rationale for dietary
modications.
Identies foods high in
carbohydrates and within protein
requirements (moderate to high
protein in cirrhosis and hepatitis, low
protein in hepatic failure).
Reports improved appetite.
Participates in oral
hygienemeasures.
Reports increased appetite;
identies rationale for smaller,
frequent meals.
Demonstrates intake of high calorie
diet; adheres to protein restriction.
Identies foods and uids that are
nutritious and permitted on diet.
Gains weight without increased
edema or ascites formation.
Reports increased appetite and well
being.
Excludes alcohol from diet.
Takes medications for
gastrointestinal disorders as
prescribed.

Nursing Interventions
1. Assess dietary intake and
nutritional status through diet
history and diary,daily weight
measurements, and laboratory
data.
2. Provide diet high in
carbohydrateswith protein intake
consistent with liver function.
3. Assist patient in identifying lowsodium foods.
4. Elevate the head of the bed
during meals.
5. Provide oral hygiene before
meals and pleasant environment
for meals at meal time.
6. Offer smaller, more frequent
meals
(6 per day).
7. Encourage patient to eat meals
and supplementary feedings.
8. Provide attractive meals and an
aesthetically pleasing setting at
meal time.
9. Eliminate alcohol.
10. Apply an ice collar for nausea.
11. Administer medications
prescribed
for nausea, vomiting, diarrhea, or
constipation.
12. Encourage increased uid

Rationale
1. Identies decits in
nutritional intake & adequacy of
nutritional
2. Provides calories for energy,
sparing protein for healing.
3. Reduces edema and ascites
formation.
4. Reduces discomfort from
abdominal distention and
decreases sense of fullness
produced by pressure of
abdominal contents and ascites
on the stomach.
5. Promotes positive
environment and increased
appetite
6. Decreases feeling of fullness
7. Encouragement is essential
for the patient with anorexia
and gastrointestinal discomfort.
8. Promotes appetite and sense
of well-being.
9. Eliminates empty calories
and further damage from
alcohol.
10. May reduce incidence of
nausea.
11. Reduces gastrointestinal
symptoms and discomforts that
decrease the appetite and
interest in food.

LIHAT DI
WORD