Medical Surgical Nursing

NURSING PROCESS FOR PATIENTS WITH HEPATIC

DYSFUNCTIONS

Nursing Diagnosis: Activity intolerance related to fatigue, lethargy, and malaise

Goal: Patient reports decrease in fatigue and reports increased ability to participate in activities

Nursing Interventions Rationale Expected Outcomes

1. Assess level of activity

tolerance and degree of fatigue,

lethargy, and malaise when

performing routine ADLs.

2. Assist with activities and

hygiene when fatigued.

3. Encourage rest when fatigued or

when abdominal pain or

discomfort occurs.

4. Assist with selection and pacing

of desired activities and

exercise.

5. Provide diet high in

carbohydrates with protein

intake consistent with liver

function.

6. Administer supplemental

vitamins (A, B complex, C, and

K).

1. Provides baseline for further

assessment and criteria for

assessment of effectiveness of

interventions

2. Promotes exercise and hygiene

within patient's level of

tolerance

3. Conserves energy and protects

the liver

4. Stimulates patient's interest in

selected activities

5. Provides calories for energy

and protein for healing

6. Provides additional nutrients

 Exhibits increased interest

in activities and events

 Participates in activities

and gradually increases

exercise within physical

limits

 Reports increased strength

and well-being

 Reports absence of

abdominal pain and

discomfort

 Plans activities to allow

ample periods of rest

 Takes vitamins as

prescribed

Nursing Diagnosis: Imbalanced nutrition: less than body requirements, related to abdominal distention and

discomfort and anorexia

Goal: Positive nitrogen balance, no further loss of muscle mass; meets nutritional requirements

1. Assess dietary intake and

nutritional status through diet

history and diary, daily weight

measurements and laboratory

data.

2. Provide diet high in

carbohydrates with protein

intake consistent with liver

1. Identifies deficits in nutritional

intake and adequacy of

nutritional state

2. Provides calories for energy,

sparing protein for healing

3. Reduces edema and ascites

formation

 Exhibits improved nutritional

status by increased weight

(without fluid retention) and

improved laboratory data.

 States rationale for dietary

modifications

 Identifies foods high in

carbohydrates and within