Kindly explain the Intervention (Independent, Dependent and… Kindly explain the Intervention (Independent, Dependent and Collaborative) base the NCP belowASSESSMENTDIAGNOSISPLANNINGINTERVENTIONRATIONALEEVALUATIONSubjective data:Patient revealed that she felt shortness of breath Objective data:- Abdominal distention- Bilateral leg edema – (+) ascites Vital Signs: BP – 140-90 mmHgRR – 27cmp Decreased albumin: 15 g/dl Diagnosis: Liver CirrhosisExcess Fluid Volume RT impaired liver functionsecondary to liver cirrhosis AEBabdominal distention, ascites,bilateral leg edema, decrease albumin, elevated BP, elevated rr Short term:After 4 hours of nursing intervention, the patient will be able to gradually improve fluid volume as AEB decrease in:- edema- ascites- Vital signs within patient’s normal range (e.g BP, temp, pr, rr) Long term:All throughout the hospitalization, the patient will be able to have a normal fluid volume AEB absence of:- edema- ascites- abdominal distention- normal albumin level (3.4-5.4 g/dL)Independent:- Assess and monitor vital signs (e.g BP, temp, pr, rr) – Assess respiratory status, noting increased respiratory rate, dyspnea- Monitor serum albumin level – Record intake and output every 1-8 hours depending on response to intervention and on patient acuity – Compare current weight with admission and/or previously stated weight. Weigh daily or on a regular schedule, as indicated. – Measure abdominal girth – Instruct patient to elevate the extremities affected area (Bilateral leg edema)- Place the patient in a semi-Fowler’s or high-Fowler’s position- Instruct patient to eat small, frequent meals – Explain rationale for sodium and fluid restriction Dependent:Administer the following medications as ordered: a. Spironolactone b. Silymarin capsule c. Potassium Collaborative:- Prepare patient and assist with paracentesis, if indicated – To have a baseline data and check for improvement of patient – Indicative of pulmonary congestion. – To monitor progression of edema and to evaluate the effectiveness of the nursing interventions and medication – Indicates effectiveness of treatments and adequacy of fluid intake – This is done to assess the patient’s volume status, development or resolution of third space shifting of body fluids and response to therapeutic management- Monitor changes in ascites formation and fluid accumulation – Helps to reduce swelling – Raising the head of bed provides comfort in breathing. – Frequent meals may be better tolerated than three large meals because of the abdominal pressure exerted by ascites. – Promotes patient understanding of restriction and cooperation with it a.To eliminate excess fluid in edema and ascites. (Diuretics rid the body of excess sodium and water in the body. This can relieve high blood pressure, edema, and shortness of breath)b.To treat Chronic Liver Disease and Cirrhosis of the liver.c. Replaces potassium that is lost as common side effect of diuretics. – Paracentesis will temporarily decrease amount of ascites. Short term:After 4 hours of nursing intervention, the patient will be able to gradually improve fluid volume as AEB decrease in:- edema- ascites- Vital signs within patient’s normal range (e.g BP, temp, pr, rr) (GOAL MET) Long term:All throughout the hospitalization, the patient will be able to have a normal fluid volume AEB absence of:- edema- ascites- abdominal distention- normal albumin level (3.4-5.4 g/dL) (GOAL MET) Health Science Science NursingNCMB 314
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