Medical Surgical Nursing

9. Provides stimulation to the

patient and opportunity for

observing the patient's level

of consciousness

Nursing Diagnosis: Risk for imbalanced body temperature: hyperthermia related to inflammatory process of

cirrhosis or hepatitis

Goal: Maintenance of normal body temperature, free from infection

1. Record temperature regularly

(every 4 h).

2. Encourage fluid intake.

3. Apply cool sponges or

icebag for elevated

temperature.

4. Administer antibiotics as

prescribed.

5. Avoid exposure to

infections.

6. Keep patient at rest while

temperature is elevated.

7. Assess for abdominal pain,

tenderness.

1. Provides baseline to detect

fever and to evaluate

interventions

2. Corrects fluid loss from

perspiration and fever and

increases patient's level of

comfort

3. Promotes reduction of fever

and increases patient's

comfort

4. Ensures appropriate serum

concentration of antibiotics

to treat infection

5. Minimizes risk of further

infection and further

increases in body

temperature and metabolic

rate

6. Reduces metabolic rate

7. May occur with bacterial

peritonitis

 Exhibits normal

temperature and reports

absence of chills or

sweating

 Demonstrates adequate

intake of fluids

 Exhibits no evidence of

local or systemic infection

Nursing Diagnosis: Ineffective breathing pattern related to ascites and restriction of thoracic excursion

secondary to ascites, abdominal distention, and fluid in the thoracic cavity

Goal: Improved respiratory status

1. Elevate head of bed to at

least 30 degrees.

2. Conserve patient's strength

1. Reduces abdominal pressure

on the diaphragm and

permits fuller thoracic

excursion and lung

 Experiences improved

respiratory status

 Reports decreased