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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