Ncp Hepatitis B
- Pages: 3
- Word count: 694
- Category: Medicine
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CUES| NURSING DIAGNOSIS| SCIENTIFIC RATIONALE| OBJECTIVES| NURSING INTERVENTIONS| RATIONALE| EVALUATION| NURSING CARE PLAN: IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS RELATED TO ANOREXIA, NAUSEA, AND ALTERED ABSORPTION AND METABOLISM SUBJECTIVE:“Diri na ako nakakakaon hin tuhay tikang jan nasakit ako. Baga diri man liwat ako gingugutom tapos kun nakaon liwat ako baga hin ginsusuka-suka ako ” as verbalized by the patient.“Nakakaabat gihap ako nga baga nanluluya tak kalawasan.” As verbalized by the patient.OBJECTIVE: * Weight of 120 lbs (baseline wt. 137.5) * Height of 5’5” * Wt loss of 17.5lbs (13%) * IBW of 136-149.6lbs * Patient was noted to be * Weak * Lethargic * Nauseated * Exhausted * With poor appetite * Irritable * cracked lips and dry mucus membrane * pale conjunctiva * Hemoglobin of 9g/dL * CBG of 76g/dL| Imbalanced Nutrition: Less Than Body Requirements related to anorexia, nausea, bile stasis, and altered absorption and metabolism| During the most severe phase of the Hepatitis B, when changes occur in the stomach or bowel, anorexia and nausea may be so extreme that oral intake of any kind is greatly reduced, leading to a common nursing diagnosis of Imbalanced nutrition.
Medical Surgical Nursing, p.1142-Black & Hawk| SHORT TERM:Within 8 hours ofeffective nursinginterventions, patientwill be able to manifest tolerance of feeding with no signs of nausea and vomiting as evidenced by: * Patient did not vomit during feeding * Patient did not complain of feeling of fullness * Patient has good appetite * Patient is no longer: * weak * Lethargic * Nauseated * Irritable * Blood glucose level in normal range: 110 mg/dlLONG TERM:After 3 days of nursing interventions the patient will be able to manifest progressive weight gain towards goal with normalization of laboratory values and no signs of malnutrion as evidenced by: * Increased weight from 120 lbs. to 126 lbs. * Absence or decreased signs of malnutrition * Muscle weakness * Exhaustion * Massive weight loss * Moist lips and mucus membranes; Pinkish conjunctiva * Hemoglobin of 13g/dL| INDEPENDENT:1. Monitor dietary intake/calorie count.2. Provide a large nutritious breakfast.3. Encourage mouth care before meals.4. Encourage the client to avoid fatty foods.5. Include optimal amount of protein and carbohydrates.6. Encourage intake of fruit juices, carbohydrate beverages, and hard candy throughout the day. 7. Recommend eating in upright position.COLLABORATIVE:1. Consult with dietician, nutritional support team to provide diet according to patient’s needs, with fat and protein intake as tolerated.2. Monitor serum glucose as indicated.DEPENDENT:1. Administer medications as indicated: – antiemetics (Metoclopramide – Reglan) – Antacids (Titralac) – Vitamins (B complex, C) – Steroid therapy (Prednisone)2. Provide supplemental feedings/TPN if indicated.| To be able to assess and monitor adequate caloric intake values to aid in the rehabilitation and restoration of nutritional status.Anorexia may also worsen during the day, making intake of food difficult later in the day. Breakfast may be the best-tolerated meal.Eliminating unpleasant taste may enhance and may enhance appetite.Fatty foods can induce nausea.This allows recovery of injured liver cells without overfeeding. If the client has no problem with protein metabolism, a normal intake is helpful for tissue repair.These supply extra calories and may be more easily digested/tolerated than other foods.Reduces sensation of abdominal fullness and may enhance intake.Useful in formulating dietary program to meet individual needs. Hyperglycemia/hypoglycaemia may develop, necessating dietary changes/insulin administration.Given 30 min before meals, may reduce nausea, and increase food tolerance.Counteracts gastric acidity, reducing irritation/risk of bleedingCorrects deficiencies and aids in the healing process.May be necessary to meet caloric requirements if marked deficits are present/symptoms are prolonged.May be necessary to meet caloric requirements if marked deficits are present/symptoms are prolonged.| Short term goals are met as evidenced by: * Patient did not vomit during feeding * Patient did not complain of feeling of fullness * Patient has good appetite * Patient is no longer: * weak * Lethargic * Nauseated * Irritable * Blood glucose level in normal range: 110 mg/dlLong term goals are met as evidenced by: * Increased weight from 120 lbs. to 126 lbs. * Absence or decreased signs of malnutrition * Muscle weakness * Exhaustion * Massive weight loss * Moist lips and mucus membranes; Pinkish conjunctiva * Hemoglobin of 13g/dL|