help please....care plan request......

  1. Here is the basic information.

    Mr. Lau 92 year old
    Diagnosis : liver failure & Hepatic cellular carcinoma
    Chief complain : Right upper quadrant pain

    Risk :
    Nutritional imbalance
    - encourage food intake
    - high protein gastric diet (Ensure 2 cans per day)

    Problem :
    1. Edema
    -exercise
    -raise leg
    -measure the circumference of calf QD
    -limit water intake
    - monitor I &O

    2. Abdominal pain
    -refer the complaint of pain to MO (no analgesic prescribed)
    - positioning
    - access the pain level, nature, positioning, onset, etc.

    Where should I start???confusing now..
    Last edit by VickyRN on Oct 19, '06 : Reason: Possible patient confidentiality breach, removed specific patient information
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  2. 16 Comments

  3. by   Daytonite
    hi, yatyu!

    you always start by making a list of of the patient's non-normal symptoms which you have done. but, let's make the list a little more concise. his problems are:
    • abdominal pain (right upper quadrant pain
    • abdominal distension
    • poor appetite
    • edema of the lower extremities
    • multiple nodules over bilateral liver lobes
    • contact bleeding because of hemorrhoids
    • abnormal liver function studies (that's labwork)
    the first thing that i am thinking of with this patient is that he has some kind of serious liver disease going on. the reason i say that is because of his abdominal distension, the abnormal liver function studies, and the multiple nodules seen on the radiological studies that were taken. if you look up liver diseases, in general, these patients usually have the following problems:
    • weakness
    • fatigue
    • weight loss
    • anorexia
    • nausea/vomiting
    • diarrhea
    • ascites
    • jaundice
    • nail changes
    • lower leg edema
    • tremors
    • delirium
    • coma (eventually)
    so, some of those things i just listed may be risk factors for your patient.

    i think the first problem that needs to be addressed is the patient's edema because edema is often related to problems with circulation or fluid excess. because these are cardiac in nature they should be listed first above any other problems.

    the next problem to list is the poor appetite. if the patient doesn't keep up his nutrition his body will break down very quickly. nutrition is also a basic physiological need.

    the next problem i would address is the one of abdominal pain. pain is a comfort issue.

    next, address the problem with the bleeding hemorrhoids

    i would also add risk for hemorrhage or confusion as these are always potential problems in patients who are facing chronic liver disease. there may also be a need for patient teaching, particular if there is going to be a need for a lot of testing. i'm thinking this patient may have cirrhosis or liver cancer. there would be extensive medical treatment if either conditions were found that the patient would need to be informed about.

    once you have this list of problems (and you don't have to use my list--after all you know this patient better than i do), then you can start to look at the nursing interventions to take to address these problems. do you need to use nanda nursing diagnoses? if not, merely look in your nursing textbooks for interventions. you were doing fine on your interventions. with edema, for example, you mention taking daily calf measurements, elevating his legs (above the level of the heart), monitoring i&o, and you should also monitor labwork, particularly protein and albumin levels.

    let me know if you need more guidance with this as i have some resources that can help you with the nursing interventions, but i am not at my home at the moment, so i don't have access to them. in the meantime you should also read some of the information on these two threads on allnurses to help you in how to write a care plan:

    http://allnurses.com/forums/f205/des...ns-170689.html
    http://allnurses.com/forums/f50/care...eb-121128.html

    good luck. welcome to allnurses!
  4. by   Daytonite
    here are some nursing interventions for this patient's problems:

    edema
    • note the location and the amount of the edema. measure calves at the same area at the same time each day.
    • monitor the condition of the patient's skin in the edematous area for evidence of skin breakdown (swollen tissue can develop pressure ulcers and ischemia)
    • keep edematous skin free of moisture from perspiration or incontinence.
    • monitor intake and output and look for any trend that would indicate decreasing output in relation to input
    • take patient's weight daily on the same scale at the same time each day.
    • restrict fluids if ordered
    • closely monitor and maintain the rate of iv fluids
    • monitor serum albumin levels (when serum albumin is low the patient's edema may become more severe)
    • check lung sounds and listen for fluid in the lung. observe for increasing evidence of difficulty breathing
    • administer diuretics as ordered.
    appetite
    • determine what the normal body weight for the patient's age and height should be.
    • obtain a baseline height and weight on the patient
    • evaluate the patient's normal diet. ask what he normally eats for meals.
    • determine patient's nutritional knowledge, what he considers normal eating practice and look for any cultural beliefs that may influence his current lack of wanting to eat
    • assess that condition of the patient's mouth, gums, tongue and teeth.
    • watch the patient eat. note how much time it takes him to each, his ability to move food from bowls to his mouth, use utensils (or chopsticks) and whether or not he becomes fatigued
    • monitor how much food the patient is able to eat at each meal
    • compare patient's food consumption with normal standards of food intake
    • determine when the patient's appetite seems to the greatest during the day and see that he receives the highest calorie meal during that time.
    • provide frequent small meals instead of larger meals
    • encourage the patient to eat by providing companionship at mealtimes.
    • give or provide for oral hygiene after meals
    • weight the patient weekly and record.
    pain
    • assess and document the locations, intensity and quality of the patient's complaints of pain
    • obtain orders for analgesics: non-narcotics + narcotics for moderate or severe pain
    • administer narcotics to keep pain at or below an acceptable level
    • if narcotics are given, monitor for sedation and respiratory depression at regular intervals of at least every 2 hours
    • also try distraction, relaxation techniques, massage and application of heat and cold to the abdomen as other ways to control abdominal pain
    • plan activities around periods of time when patient's pain is relieved.
    hemorrhoids
    • notify physician that patient has blood with passage of stool.
    • monitor the patient for constipation. note amount and frequency of bowel movements and the consistency of his stools.
    • ask patient about any pain or itching he might have brought on by bowel movements
    • assess if there are any foods he eats that cause his hemorrhoids to become irritated and eliminate them from his diet.
    • include more fruits and vegetables in the patient's diet to increase fiber content
    • request medication from physician to relieve any itching of hemorrhoids
    • if patient is receiving narcotics for pain ask the physician for orders for stool softeners
  5. by   yatyu
    thanks a lot~daytonite~~u're so kind....
  6. by   allthingsbright
    please tell me this is a hypothetical patient? if not you need to get rid of all personal information.

    sorry, but it freaks me out to see patient info like this and there is not any indication that this is hypothetical. hippa, hippa, hippa.
    Last edit by allthingsbright on Oct 19, '06
  7. by   allthingsbright
    PS I see she is in Hong Kong...so maybe it isnt a big deal? HM...
  8. by   Daytonite
    Quote from allthingsbright
    please tell me this is a hypothetical patient? if not you need to get rid of all personal information.

    sorry, but it freaks me out to see patient info like this and there is not any indication that this is hypothetical. hippa, hippa, hippa.
    english is only a co-primary language in hong kong which is under the sovereign rule of the people's republic of china. most of their citizens write in chinese using chinese characters. what looks like an english surname to us is actually a phonetic translation. "lau" is a very common surname, much like smith is to us. it may also have several different english spellings as well depending on who did the actual phonetic translation. there is also a second part to the surname which the poster eliminated, so no patient identification could be made. i know this because many of my friends are from hong kong and some still use their chinese names.

    hipaa, not hippa, relates to a u.s. american federal law, the health insurance portability and accountability act, which was passed back in 1996 primarily to regulate the standards in the electronic transmission of healthcare information across the internet and fax lines, particularly in the payment of medical insurance claims. how this has degenerated into the widespread paranoia among healthcare providers that big brother hipaa is gonna get you if you break patient confidentiality is amazing to me. patient confidentiality has always been something i was taught since i started nursing school in the early 1970's long before hipaa legislation was even an idea in someone's mind. the hipaa forms that healthcare facilities have you read and sign before you even receive treatment are all about the sharing of your healthcare information with third party payers or government agencies that require the collection of certain information by law. to that end, everything that goes in the patient's chart, any part of which is ultimately subject to being transmitted by electronic means to medicare, medicaid or an insurance company for payment or the collection of data is, therefore, confidential information. most of us didn't need a law to tell us that. some unscrupulous insurance companies, however, did. viola, hipaa legislation.
  9. by   allthingsbright
    Quote from daytonite
    english is only a co-primary language in hong kong which is under the sovereign rule of the people's republic of china. most of their citizens write in chinese using chinese characters. what looks like an english surname to us is actually a phonetic translation. "lau" is a very common surname, much like smith is to us. it may also have several different english spellings as well depending on who did the actual phonetic translation. there is also a second part to the surname which the poster eliminated, so no patient identification could be made. i know this because many of my friends are from hong kong and some still use their chinese names.

    hipaa, not hippa, relates to a u.s. american federal law, the health insurance portability and accountability act, which was passed back in 1996 primarily to regulate the standards in the electronic transmission of healthcare information across the internet and fax lines, particularly in the payment of medical insurance claims. how this has degenerated into the widespread paranoia among healthcare providers that big brother hipaa is gonna get you if you break patient confidentiality is amazing to me. patient confidentiality has always been something i was taught since i started nursing school in the early 1970's long before hipaa legislation was even an idea in someone's mind. the hipaa forms that healthcare facilities have you read and sign before you even receive treatment are all about the sharing of your healthcare information with third party payers or government agencies that require the collection of certain information by law. to that end, everything that goes in the patient's chart, any part of which is ultimately subject to being transmitted by electronic means to medicare, medicaid or an insurance company for payment or the collection of data is, therefore, confidential information. most of us didn't need a law to tell us that. some unscrupulous insurance companies, however, did. viola, hipaa legislation.
    thanks for the info, daytonite. you are throrough, as always.
  10. by   yatyu
    Sorry.....As starting for my careplan, I make some diagnosis....could someone help me to see if it is appropriate....

    1) excess fluid volume r/t liver failure
    2) RUQ pain r/t hepatic maglinancy and liver enlargement
    3) Acitivity intoleranrance r/t ascites and edema
    4) Risk For Impaired skin integrity r/t edema
    5) Risk for nutrient imbalance r/t hypoalbuminemia
    6) Risk for bedsore r/t immotility

    As deadline is comming, please comment them~~~~Thanks!!!

    Also, I would like to ask ............do edema and ascites both related to his liver failure? if yes...should I put them in the same nursing diagnosis(excess fluid volume) but in different outcomes and nursing interventions? thanks
    Last edit by yatyu on Nov 13, '06
  11. by   Daytonite
    is this care plan for the same patient, you've listed above at the very start of this thread? in my first reply to the post i mention that edema and ascites are both problems of liver failure. here is a link that includes the pathophysiology of liver failure.
    http://www.clevelandclinic.org/healt...asp?index=9494
    http://www.emedicine.com/med/topic990.htm
    http://www.cancer.gov/cancerinfo/wyntk/liver - what you need to know about liver cancer

    i gave you some interventions previously for the edema. treatment of ascites is dependent on what the doctor orders or the procedures they do on the patient. outcomes are based on the nursing diagnosis and the interventions you choose. for example, since one of your nursing diagnoses has to do with preventing the patient from developing a bedsore, then your outcome is going to be that no bedsore develops. all the nursing interventions that you put with that particular nursing diagnosis lead to that outcome. if you go back into the "desperately need help with careplans" thread you will find that i recently posted some information about outcomes and goals.

    in your above list of diagnoses, a bedsore and impaired skin integrity are the same idea. there is no nursing diagnosis of "bedsore". if a person gets a bedsore we use the nursing diagnosis of impaired skin integrity. one thing that you will find about working with nanda nursing diagnoses is that the words that you use are important. that is a big factor in the writing of the nursing diagnoses.

    i am re-writing your nursing diagnoses in the current nanda language and using their current rules. nanda, with very few exceptions, does not want nurses to use medical diagnoses in the writing of nursing diagnoses. nursing diagnoses should be prioritized using some sort of system, such as maslow or gordon, as a guide. even within your section of "risk for" nursing diagnoses, which are problems that do not really exist, there should be prioritization. therefore, a potential problem of nutrition will come before impaired skin for the very simple reasoning that without food and water a person dies a lot faster than they will from the impaired skin.
    this is how i would suggest you change your list:
    • excess fluid volume r/t sodium retention or lowered plasma colloidal osmotic pressure (pick one or use both)
    • chronic pain r/t enlargement of tumor in liver
    • activity intolerance r/t weakness and immobility
    • risk for imbalanced nutrition: less than body requirements r/t increased metabolic demands of tumor, altered protein, fat and glucose metabolism, and the impaired storage of vitamins a, c, k, d, and e
    • risk for impaired skin integrity r/t pressure and immobility
  12. by   yatyu
    Could I use laboratory result for supporting the diagnosis?

    For example, Excess Fluid Volume R/T sodium retention or lowered plasma colliodal osmotic pressure AEB higher level of Total Bilirubin, ALP, creatinine and lower level of albumin
  13. by   Daytonite
    Yes, you can because they are abnormal pieces of data that support the nursing diagnosis and what is causing it. I would actually list the results, for example "total bilirubin of 50, alkaline phosphatase of 120 and serum albumin of 2.0". So, I would end up with a nursing diagnostic statement like this:
    • Excess Fluid Volume R/T sodium retention or lowered plasma colloidal osmotic pressure AEB total bilirubin of 50, alkaline phosphatase of 120 and serum albumin of 2.0.
  14. by   yatyu
    As I am working on risk for imbalance nutrition, I want to ask how could I determine the ideal weight? or just maintain his current weight? thanks!

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