# 2 VITAL SIGNS BP 97/50 T 37.

2 SaO2 96% 2L NC Pain level 2/10

# 3 NEURO Alert, oriented x1 Confused Pupils slow reactivity Verbal response is delayed Reflexes intact Lisa Carlos # 4 RESPIRATORY Clear lungs 2L NC Equal bilaterally Labored breathing # 5 CARDIOVASCULAR Equal radial/pedal pulses. No audible rubs or murmurs Capillary refill within 2 seconds

CONCEPT MAP

HR 82 RR 12

# 7 PATIENT SAFETY ISSUES Fall risk r/t altered LOC

cranial nerves intact # 1 PATIENT DESCRIPTION JB

# 8 GI/NUTRITION/BMI Diarrhea; hyperactive bowel sounds Ascites #9 WNL GU/ELIMINATION

49 y/o male 59 180 lbs Dx: ALOC Hx: HTN, Liver disease, ETOH, substance abuse Allergies: Iodine, PCN # 12 DISCHARGE/EDUCATION NEEDS Cessation of alcohol intake

# 6 MUSCULOSKELETAL/SKIN Full ROM Immobile due to ascites Bruising Skin turgor slow to return back to normal

NURSING DIAGNOSES
# 10 PSYCHOSOCIAL/COMFORT Ineffective coping

# 11 FAMILY/CAREGIVER 2ND NURSING DIDAGNOSIS ISSUES/FINANCES/RESOURCES Acute Confusion r/t increased serum Married, 2 children who were not present. ammonium level 2 ETOH

Lisa Carlos

1ST NURSING DIAGNOSIS Imbalanced nutrition: less than body requirements r/t abdominal distention, discomfort, and anorexia ACTIONS ACTIONS PATIENT JB: Altered LOC

Continue patients usual rituals, to limit anxiety

Offer smaller, more frequent meals Assess dietary intake and nutritional status

3RD NURSING DIAGNOSIS Activity Intolerance r/t impaired respiratory function 2 ascites

ACTIONS Name:__Lisa Carlos__ Date: 2 / 01 /12 Section:_40__ Facility:__EMC__ Date admit:_____ Assess Care Planlevel of activity tolerance and (This page and citation page must be typed and single spaced, can expand the rowsperforming more than one page, 12 pt font) degree of fatigue when to include

routine ADLs.

Lisa Carlos Nursing Diagnoses (3) Goal Interventions/citations Evaluation (goal)

1. Imbalanced nutrition: less than body requirements r/t abdominal distention, discomfort, and anorexia 2 alcohol dependence AEB: diarrhea, hyperactive bowel sounds, pale mucous membranes, reported altered taste sensation

Patient will: Maintain weight at 180 lbs. Tolerate prescribed diet Have laboratory values within normal limits Report adequate energy levels

Assess dietary intake and nutritional status Weight has been through diet history and diary, daily weight managed. measurements, and laboratory data (Identifies deficits in nutritional intake and adequacy of nutritional state.) (Smeltzer,
S. C. 2010)

Appetite increased. Elevation of HOB alleviated pressure on abdomen Denial of substance abuse problems

Assist patient in identifying low-sodium foods (reduces edema and ascites formation)
(Smeltzer, S. C. 2010)

Elevate the HOB during meals (Reduces discomfort from abdominal distention and decreases sense of fullness produced by pressure of ascites on the stomach.) (Smeltzer, S. C. 2010) Offer smaller, more frequent meals (decreases feeling of fullness, bloating.)
(Smeltzer, S. C. 2010)

Eliminate alcohol

Lisa Carlos

(eliminates empty calories and further damage from alcohol.) (Smeltzer, S. C.

2010)

Administer medications prescribed for diarrhea (reduces GI symptoms and discomfort that decreases appetite) (Smeltzer, S. C.
2010)

2. Acute Confusion r/t increased serum ammonium level 2 ETOH AEB: ammonium level 102, fluctuation in level of consciousness, increased agitation, and restlessness

Patient will: Demonstrate cognitive orientation Make lifestyle and behavior changes to alleviate or prevent further episodes of confusion Demonstrate decreased restlessness and agitation

Delirium management: Provision of a safe and therapeutic environment for the patient who is experiencing an acute confusional state. Continue patients usual rituals, (to limit anxiety) (Smeltzer, S. C. 2010) Be sure patient wears an identification bracelet Orient patient, as needed

Level has been reduced, alert oriented x2 Easily identifiable Does not need to be oriented and aroused with much effort Anxiety and agitation remain unchanged

3. Activity Intolerance r/t impaired respiratory

Patient will:

Assess level of activity tolerance and degree of fatigue when performing routine ADLs.

Tolerance level slightly improved. Able to sit up in bed and use bedside

Lisa Carlos

function 2 ascites AEB:

Report decrease in fatigue Report increased ability to participate in activities

(provides baseline for further assessment)

(Smeltzer, S. C. 2010)

commode. Able to assist with bathing and eating. Has not reported Abdominal discomfort.

Encourage rest when fatigued or when abdominal pain or discomfort occurs. (conserves energy and protects the liver)
(Smeltzer, S. C. 2010)

Provide diet high in carbohydrates with protein intake consistent with liver function (provided calories for energy and protein for healing) (Smeltzer, S. C. 2010)
References End Notes 1. Smeltzer, S. C. (2010). assessment and management of patients with hepatic disorders. Brunner & Suddarth's textbook of

medical-surgical nursing (12th ed., pp. 1117-1166). Philadelphia: Lippincott Williams & Wilkins.

Lisa Carlos

GRADING RUBRIC FOR THE CARE PLAN

The care plan must be stapled, typed, your name on it, and all components included (concept map, nursing diagnosis sheet, either physical assessment or SBAR sheet, nursing care plan sheet, reference sheet in APA format) Please abide by HIPAA CRITERIA Pertinent data is collected and in the appropriate areas on the concept map, SBAR/Physical assessment sheet Nursing diagnoses (3) are: clearly supported by the data correctly stated prioritized correctly Nursing outcomes are: SMART appropriate for the nursing problem Nursing interventions are: appropriate for the nursing problem written correctly with time frames as applicable thorough clearly defines the students scope of practice (out of scope is written in blue) Nursing interventions are: supported with rationales from appropriate sources (not a care plan book) cited correctly in APA format Nursing evaluations: address the goal explain why goal met/not met explain further action needed as applicable Reference sheet is written in correct APA format TOTAL POINTS POINTS POSSIBLE 2 3 2 3 POINTS

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