Medical Surgical Nursing

function.

3. Assist patient in identifying

low-sodium foods.

4. Elevate the head of the bed

during meals.

5. Provide oral hygiene before

meals and pleasant environment

for meals at meal time.

6. Offer smaller, more frequent

meals (6 per day).

7. Encourage patient to eat meals

and supplementary feedings.

8. Provide attractive meals and an

aesthetically pleasing setting at

meal time.

9. 
   

   Eliminate alcohol.

   
   


10. 
    

    Apply an ice collar for nausea.

    
    


11. 
    

    Administer medications

    
    

prescribed for nausea, vomiting,

diarrhea, or constipation.

12. Encourage increased fluid

intake and exercise if the patient

reports constipation.

4. Reduces discomfort from

abdominal distention and

decreases sense of fullness

produced by pressure of

abdominal contents and ascites

on the stomach

5. Promotes positive environment

and increased appetite; reduces

unpleasant taste

6. Decreases feeling of fullness,

bloating

7. Encouragement is essential for

the patient with anorexia and

gastrointestinal discomfort.

8. Promotes appetite and sense of

well-being

9. Eliminates ̳empty calories‘

and further damage from

alcohol

10. May reduce incidence of

nausea

11. Reduces gastrointestinal

symptoms and discomforts that

decrease the appetite and

interest in food

12. Promotes normal bowel

pattern and reduces abdominal

discomfort and distention

protein requirements

(moderate to high protein in

cirrhosis and hepatitis, low

protein in hepatic failure)

 Reports improved appetite

 Participates in oral hygiene

measures

 Reports increased appetite;

identifies rationale for

smaller, frequent meals

 Demonstrates intake of high-

calorie diet; adheres to protein

restriction

 Identifies foods and fluids

that are nutritious and

permitted on diet

 Gains weight without

increased edema or ascites

formation

 Reports increased appetite

and well-being

 Excludes alcohol from diet

 Takes medications for

gastrointestinal disorders as

prescribed

 Reports normal

gastrointestinal function with

regular bowel function

7. Nursing Diagnosis: Impaired skin integrity related to pruritus from jaundice and edema

Goal:Decrease potential for pressure ulcer development; breaks in skin integrity.

8. 
   

   Nursing Interventions Rationale Expected Outcomes

   
   


9. 
   

   Assess degree of discomfort

   
   

related to pruritus and edema.

10. Note and record degree of

1. Assists in determining

appropriate interventions

2. Provides baseline for detecting

 Exhibits intact skin

without redness,

excoriation, or breakdown