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:
- weight loss
- nail changes
- lower leg edema
- 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:
good luck. welcome to allnurses!