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Saturday, November 26, 2011

Nursing Care Plan for Hepatitis : Assessment, Diagnosis and Interventions

ASSESSMENT OF NURSING CARE PLAN FOR HEPATITIS

Basic data depends on the cause and severity of the damage / hepatic impairment
  1. Activity
    • Weakness
    • Fatigue
    • Malaise
  2. Circulation
    • Bradycardia (Hiperbilirubin weight)
    • Jaundice in the sclera of the skin, mucous membranes
  3. Elimination
    • Dark urine
    • Diarrhea stool color clay
  4. Food and Fluids
    • Anorexia
    • Weight loss
    • Nausea and vomiting
    • Increased edema
    • Ascites
  5. Neuro-sensory
    • Sensitive to stimuli
    • Tend to sleep
    • Lethargy
    • Asterixis
  6. Pain / Leisure
    • Abdominal cramps
    • Tenderness in the right quadrant
    • Myalgia
    • Arthralgia
    • Headache
    • Itching (pruritus)
  7. Security
    • Fever
    • Urticaria
    • Lesions makulopopuler
    • Erythema
    • Splenomegaly
    • Posterior cervical lymph node enlargement
  8. Sexuality
    • Lifestyle / behavior increases the risk of exposure

DIAGNOSIS OF NURSING CARE PLAN FOR HEPATITIS

Some nursing issues, which may arise in patients with hepatitis:

1. Imbalanced Nutrition Less Than Body Requirements
related to:
  • discomfort in the upper right quadrant,
  • impaired absorption and metabolism of food digestion,
  • input failure to meet the metabolic demands because of anorexia, nausea and vomiting.

2. Acute pain
related to:
  • swelling of the liver is inflamed liver and portal vein dam.

3. Hyperthermia
related to:
  • invasion agents in the blood circulation secondary to liver inflammation.

4. Fatigue
related to:
chronic inflammatory process secondary to hepatitis.

5. Risk for impaired tissue integrity
related to:
pruritus secondary to accumulation of bilirubin pigments in bile salts.

6. Risk for infection
related to:
  • the nature of the infectious viral agent.

INTERVENTIONS AND RATIONAL OF NURSING CARE PLAN FOR HEPATITIS

1. Imbalanced Nutrition Less Than Body Requirements:
  • Teach and assist the client to rest before eating
    Rationale: Fatigue continues down the desire to eat.
  • Watch the dietary intake / amount of calories, offer to eat little but often and most often offer morning.
    Rational: The enlargement of the liver can suppress the gastro intestinal tract and reduce its capacity.
  • Maintain good oral hygiene before meals and after meals.
    Rational: The accumulation of food particles in the mouth can add new flavor and odor which decreases appetite.
  • Encourage eating in an upright sitting position.
    Rational: Lowering the feeling of fullness in the abdomen and can increase revenue.
  • Give diit high in calories, low in fat.
    Rationale: Glucose in carbohydrates is effective enough to meet energy, while fat is difficult to be absorbed / metabolized so that it will burden the liver.
2. Acute pain :
  • Collaboration with individuals to determine the method can be used for the intensity of pain
    Rational: Pain-related hepatitis is not very convenient, because there is stretching the liver capsule, through the approach to individuals who experience pain comfort changes are expected to more effectively reduce the pain.
  • Indicate the client's acceptance of the client's response to pain
    • Acknowledge the pain
    • Listen attentively to client's expression of pain
    Rational: Klienl should try to convince health providers that he was experiencing pain.
  • Provide accurate information and
    • Explain the causes of pain
    • Indicate how long the pain will end, if known
    Rationale: Clients who are prepared to experience the pain through the explanation of the real pain will be felt (clients tend to be quieter than the explanation is less / no explanation)
  • Discuss with your doctor the use of analgesics that do not contain hepatotoxic effects.
    Rational: The possibility of pain already can not be limited to techniques for reducing pain.
3. Hyperthermia
  • Monitor vital signs: body temperature
    Rational: As an indicator to know the status hypertermia.
  • Teach clients the importance of maintaining adequate fluid to prevent dehydration, such as fruit juice from 2.5 to 3 liters / day
    Rational: In febrile conditions an increase in evaporation that trigger the onset of dehydration.
  • Give a warm compress on the folds of the armpits and the femur.
    Rational: Inhibit the sympathetic centers in the hypothalamus, causing skin vasodilatation by stimulating the sweat glands to reduce body heat through evaporation.
  • Encourage clients to wear clothing that absorbs sweat.
    Rational: Skin conditions that have lead to damp the growth of fungi. Will also reduce the client's comfort, preventing the onset of skin rash.
4. Fatigue
  • Explain the causes of individual fatigue
    Rationale: With the explanation causes of fatigue, the condition of clients tend to be quiet
  • Advise clients to bed rest
    Rational: Bed rest will minimize metabolic energy expenditure that can be used to cure diseases
  • Help individuals to identify strengths, abilities and interests
    Rationale: Allows clients to prioritize activities are very important and minimizing energy expenditures for activities that are less important.
  • Analysis together for 24-hour level of fatigue include energy peak time, when fatigue, fatigue-related activities
    Rationale: Fatigue may be minimized by reducing activities that can lead to fatigue.
  • Help to learn about effective coping skills (assertiveness, relaxation techniques)
    Rationale: To reduce fatigue both physical and psychological.
5. Risk for impaired tissue integrity
  • Maintain cleanliness without causing dry skin.
    • Frequent bathing with cold water and mild soap.
    • Dry skin, tissue rubbed.
    Rational: Drought increases the sensitivity of the skin by stimulating the nerve endings.
  • Prevent excessive heating to keep the cold room temperature and low humidity, avoid clothes too thick.
    Rational: Warming the excessive increase of pruritus by increasing the sensitivity through vasodilation.
  • Advise not to scratch, instruct the client to provide a strong pressure on the area of ​​pruritus for the purpose of scratching.
    Rational: Replacement stimulates the release of hidtamin, produce more pruritus.
  • Keep indoor humidity at 30% -40% and cold.
    Rationale: Cooling will reduce vasodilation and moisture drought.
6. Risk for infection
  • Use caution on the substance of the right body to handle all body fluids
    • Wash hands before and after contact with all clients or specimens
    • Use gloves for contact with blood and body fluids
    • Place the syringe which was used immediately in the proper containers, do not close the back or in any way manipulate the needle
    Rationale: Prevention may decide the method of transmission of hepatitis virus
  • Use the techniques of infectious waste disposal, linen and body fluids with proper equipment to clean and contaminated surfaces
    Rational: This technique helps protect others from contact with infectious material and prevent transmission of disease
  • Explain the importance of washing hands frequently with clients, families and other visitors and health care workers
    Rational: Hand washing removes harmful organisms chain of transmission of infection
    Refer to the infection control officer for the proper evaluation of the health department
  • Rationale: Referral is necessary to identify sources of exposure and possibly others infected.
Articles Source from : http://nursing-care-plan.blogspot.com/2011/11/nursing-care-plan-for-hepatitis.html

Related Articles :
Pathophysiology of Hepatitis

2 komentar:

Rowina Martinez said...

very useful! I now know where i can refer to for more effective care of my patients.

Rowina Martinez said...

love these nursing diagnosis!

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