Liver Abscess - 7 Nursing Diagnosis, Interventions and Evaluation

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Liver Abscess - 7 Nursing Diagnosis, Interventions and Evaluation

Nursing Diagnosis, Interventions and Evaluation for Liver Abscess

1. Breathing pattern, ineffective related to Neuromuscular, imbalance perceptual / cognitive.

Goal : normal breathing pattern / effective and free from signs of cyanosis or hypoxia .

Intervention :

• Maintain the patient's airway by tilting the head.
• Auscultation of breath sounds.
• Observation of the frequency and depth of breathing, the muscles use the respirator.
• Monitor vital signs continuously.
• Do the motion as soon as possible.
• Observation of the excess.
• Do suction mucus when necessary.
• Provide supplemental oxygen as needed.
• Give treatment as instructed.

2. Disturbed Sensory Perception : the process of thought related to chemical changes : the use of pharmaceutical drugs.

Goal : increasing the level of awareness

Intervention :

• Orient the patient back continuously after coming out of the influence of anesthesia.
• Talk with the patient in a clear voice and normal.
• Minimize negative discussion.
• Use the pads on the edge, do binding if necessary.
• Observations of the existence of hallucinations, depression and others.
• Maintain a calm and comfortable environment.

3. Fluid Volume Deficit, Risk for oral fluid intake restriction (process / medical procedure / nausea).

Goal : there is adequate fluid balance .

Intervention :

• Measure and record the input and output.
• Assess urinary spending, especially for the type of surgical procedure performed.
• Monitor vital signs.
• Note the emergence of nausea / vomiting, history of motion sickness.
• Check the pads, appliance drein at regular intervals , examine the wound for swelling.
• Give parenteral fluids, blood products and / or plasma expanders as directed. Level IV speed if necessary.
• Give back oral intake gradually as directed.
• Give antiemetics as needed.

4. Pain (acute) related to disorders of the skin, tissue, and muscle integrity.

Goal : pain has been controlled / eliminated, the client can rest and activity according to ability.

Intervention :

• Assess pain scale, intensity, and frequency.
• Evaluation of pain on a regular basis.
• Assess vital signs.
• Assess the cause of the discomfort that may be appropriate operating procedures.
• Put repositioning as directed.
• Encourage use of relaxation techniques.
• Give medicines as directed.

5. Impaired Skin Integrity related to the interrupt mechanism of the skin / tissue.

Goal : to improve the metabolic action shows.

Intervention :

• Review the functional capabilities and circumstances.
• Place the client in a particular position.
• Keep the body well-being functionally.
• Help or actions to perform range of motion exercises.
• Give skin care carefully.
• Monitor urine output.

6. Risk for infection related to an operating wounds and invasive procedures.

Goal : There are no signs and symptoms of infection

Intervention :

• Provide anti-septic and aseptic care, maintain good hand washing.
• Observations damaged skin area (stitches) attached regions invasive tool.
• Monitor the entire body on a regular basis, record the presence of fever, chills, and diaphoresis.
• Keep an eye or the number of visitors.
• Give antibiotics as indicated.

7. Disturbed Sleep Pattern related to the disease process, the effects of hospitalization, changes in the environment.

Goal : resting needs can be met

Intervention :

• Assess the client's ability and sleeping habits.
• Provide a comfortable bed with a few personal belongings. Example : pillows, bolsters.
• Suggest to light activity.
• Suggest to take action relaxation.
• Encourage the family to always accompany.
• Supervise and limit the number of visitors.

8. Knowledge deficit (learning need) regarding condition / situation, prognosis, treatment needs.

Goal : Declare, understanding of disease processes / pragnosis.

Intervention :

• Revisit surgery / special procedures performed and on future expectations.
• Discuss drug therapy , including the use of a prescription.
• Identification of specific activity limitations.
• Schedule an adequate period of rest.
• Emphasize the importance of further visits.
• Involve famous people in the teaching program. Provide written instructions / teaching materials.
• Repeat the importance of diet and fluid intake adequate nutrition.

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