NURSING CARE PLAN

Name of Patient: Mangku Kowlam Date Admitted: May 7, 2022 Chief Complaint: Hepatic Failure and Hypotension Case Number: 1

Age: 14 years old Gender: Male Civil Status: Single Address: Los Banos Laoang AP: Jonathan Mercado Raul Sy
 NURSING GOALS AND
ASSESSMENT RATIONALE NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES
Subjective Data: Fluid Volume, risk for Febrile states influence the Short Term Goals and Independent: Independent: Short term Goal and
deficiency related to; decrease of body fluids and Objectives: 1. Establish rapport to the 1. In order to achieve Objectives:
“My son had been hypermetabolic state as susceptible to increased patient patient’s active
evident by fever; perspiration. Decreased Within 5 hours of providing cooperation and trust Within 24 hours of patient
vomiting 2 days prior to
nursing care, the patient will 2. To help patient drink
confinement” decreased fluid intake, fluid intake, associated with 2. Encourage fluid intake care, desired outcomes are met
be able to:
vomiting; altered vomiting contributes to water to replace loss and patient is:
 Maintain hydration
“He had been drinking clotting process; and overall fluid volume and water from vomiting.  Able to maintain
 Increase fluid intake
less water from the past third space shift may result to severe  Achieve stable vital 3. Monitor patient’s fluid 3. Monitoring I&O helps proper hydration
few days” evident by abnormal dehydration. Damaged liver signs in order to intake and Output clinicians determines the  Able to increase fluid
coagulation studies. may influence blood decrease risk of patient’s hydration intake
clotting factor and heme fluid deficit status and ensure  At stable vital signs
metabolism which may  Free from signs and adequate fluid intake for  Clear from signs and
induce fluid shifts. risk of hemorrhage proper dehydration
Objective Data: risk of hemorrhage
4. Note active reoccurrence 4. Vomiting influences
of vomiting fluid input and Provides Long Term Goals and
 Temperature Long Term Goals and
Objectives: information about Objectives:
104OF
replacement needs.
 Coagulation
Within 3 days of nursing Vomiting can also cause Within 3 days of patient care,
studies:
intervention, the patient will: decrease fluid volume the desired goals are now met
prothrombin time  Be able to verbalize and may cause and the patient is:
24.4 sec, APTT awareness of dehydration
52, INR 2.4, causative factors  Able to verbalize
5. Assess peripheral pulse, 5. Indicators for blood
fibrinogen 412 that contributes to awareness of the
capillary refill, and circulation volume and
mg/dL, factor V fluid deficits causative factors that
mucous membrane perfusion
activity 39%  Be able to state contributes to fluid
measures to which 6. Check for edema 6. Useful for monitoring
(normal range deficiency
fluid deficit and formation progression of fluid shift
70%-120%),  Able to state
dehydration could 7. Have patient utilize 7. Using swabs and
factor VII 19% measures to which
be avoided. cotton swab or mouth mouthwash instead of
(normal range fluid volume deficit
instead of toothbrush toothbrush reduces risk
70%-130%) and dehydration
of mouth trauma and
factor V Leiden - could be avoided
bleeding of gums
absent,
8. Observe signs of 8. Clotting factors and
bleeding coagulation times are
affected due to damaged
liver

Collaborative: Collaborative:
1. Monitor periodic 1. Monitoring these lab
laboratory values such as values reflects hydration
albumin, Na and Hb/Hct and identifies protein
deficits, sodium
retention, and clotting
deficits
2. Provide I.V. fluids or 2. Provides fluid to replace
loss