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Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

The nursing assessment identified a patient with impaired bowel elimination pattern related to decreased liver function as evidenced by changes in bowel habits and liver enzyme levels. The short term goal was to establish normal bowel pattern within 8 hours with nursing interventions like assessing bowel habits, administering oral rehydration and advising a low protein diet. The long term goal was to maintain normal bowel elimination in 3 days with continued interventions and advising on potential liver transplantation. The plan would be evaluated based on achieving normal bowel habits.

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Mara Jon Ocden Casiben
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215 views4 pages

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

The nursing assessment identified a patient with impaired bowel elimination pattern related to decreased liver function as evidenced by changes in bowel habits and liver enzyme levels. The short term goal was to establish normal bowel pattern within 8 hours with nursing interventions like assessing bowel habits, administering oral rehydration and advising a low protein diet. The long term goal was to maintain normal bowel elimination in 3 days with continued interventions and advising on potential liver transplantation. The plan would be evaluated based on achieving normal bowel habits.

Uploaded by

Mara Jon Ocden Casiben
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE DATA: Impaired bowel STG: Assess the frequency of bowel pattern Assessment aids in diagnosis & STG:
 Change in bowel elimination After 8 hours of nursing providing appropriate interventions
habits like alternate pattern r/t change intervention, the patient will In case of diarrhea, asses the color, To replace the fluids according to the After 8 hours of nursing intervention,
episodes of diarrhea in bowel habits as be able to: consistency & frequency of stools loss short term goal is fully achieved as
& constipation alternate episodes  evidenced by:
 Hematemesis of constipation & Administer oral rehydration solution To replace the fluids & prevent
diarrhea LTG: after every loose stools dehydration 
 Dyspepsia
 Abdominal bloating secondary to After 3 days of nursing Advice the client to take the fluids as To prevent constipation & dehydration
decreased intervention the patient will be LTG:
& pain advised
 Black & tarry stools metabolic function able to: After 3 days of nursing intervention,
of the liver  Client will be able to Advice the client to take carbohydrate To treat constipation long term goal is fully achieved as
OBJECTIVE DATA: maintain a normal & fiber rich foods like wheat bran &
evidenced by:
 Fetor Hepaticus bowel elimination oranges as prescribed
(Sweet odor of pattern with regular Administer dulcolax syrup or To increase peristalsis & aid in stool  Client maintained a normal
breath) bowel habits suppositories as prescribed elimination bowel elimination pattern
 Distended abdomen Administer proctolysis enema as To eliminate the stools with regular bowel habits
 Pain in the right prescribed in case of constipation
hypochondriac region Provide bowel wash with laxatives To eliminate the stools & prevent
of abdomen once every 6 hours in case of sever hepatic encephalopathy
 Loose stools or black constipation
& tarry stools/ Administer IV fluids like colloids To prevent dehydration & maintain
straining at stools &crystalloids as prescribed fluid volume status
 Irregular bowel Advice to take low protein diet As the liver cannot metabolize the
sounds protein they can build up the intestinal
 Stools for occult ammonia and cause encephalopathy
Blood Positive Place the client on molecular To temporarily support the liver
 Abdominal palpation absorbent recirculating system if function and improve the bowel habits
shows hepatomegaly needed of the client
 Presence of anal/ Advice the client on the need for liver To replace the liver function and aid in
sacral edema transplantation and prepare for the metabolism of foods thereby improves
 Hypoalbuminemia surgical procedure, if indicated in end the bowel pattern
 Elevated liver of stage liver disease
enzymes
 Liver ultrasound
reveals fatty or
fibrous scarring of the
liver
 Liver Biopsy shows
fibrosis & scarring of
Liver tissue
a

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