II.Nursing Diagnosis
• Acute pain
• Imbalanced nutrition: less than body requirements
• Excess or deficient fluid volume
• Risk for infection
• Risk for impaired skin integrity
• Activity intolerance
• Deficient knowledge
• Disturbed thought processes
• Disturbed body image
III.Planning and Outcome Identification
• The major goals for a client diagnosed with a hepatic, biliary, or pancreatic disorder include relief of pain and discomfort, improved nutritional and fluid status, decreased potential for injury and infection, maintenance of skin integrity, increased activity intolerance, understanding of disease process and treatment, and improved mental status and body image.
IV.Implementation
Provide pain relief.
• Asses the client’s pain, rule out complications, medicate or intervene as appropriate, institute safety measures (side rails up, call light within reach), and evaluate the effectiveness of pain medication.
Promote nutritional balance.
• Assess nutritional status through diet history, provide appropriate diet for condition, and collaborate with a dietitian.
• Provide oral hygiene before meals.
• Ensure a pleasant environment for meal times.
Provide ongoing assessment.
• Assess all emesis and stool (e.g. bright red blood, occult blood, steatorrhea)
• Measure and record daily weight, intake and output, and abdominal girth
• Monitor and assess vital signs every 4 hours, watch for changes from baseline values.
• Assess for signs and symptoms of infection
Promote measures to increase activity intolerance.
• Assist with selecting and pacing of activities, encourage rest, and assist with performing activities and hygiene when fatigued.
Protect skin integrity.
• Institute measures that help prevent skin breakdown, such as turning the client every 2 hours and using pressure-relieving devices.
Enhance mental status.
• Assess the client’s level of consciousness, keep the client oriented to environment, and instruct the client to report mental confusion or lethargy at once.
Provide client and family teaching.
• Instruct the client on the cause of the disorder, signs and symptoms to report to a health care provider, interventions aimed at preventing complications and appropriate administration of medications.
• Provide health education.
Promote a positive body image.
• Encourage the client to verbalize feelings about body image and self-concept changes.
V.Outcome Identification
• The client reports decreased pain with minimal discomfort.
• The client maintains nutritional status, maintains adequate fluid and nutrient intake, and verbalizes understanding of dietary recommendations to help control symptoms.
• The client maintains adequate electrolyte imbalance, has no change in weight or abdominal girth, and maintains adequate intake and output.
• The client displays no evidence of infection or injury.
• The client exhibits intact, uncompromised skin integrity with no evidence of jaundice.
• The client reports decreased fatigue with activity.
• The client verbalizes understanding of preventive measures, self-care to maintain health status and understanding of the disorder and procedures used.
• The client demonstrates improved mental status and increased level of consciousness.
• The client verbalizes feelings about body image and self-concept.