Anatomy of Hepar

divided

smaller left lobe

large right lobe

Histologically, the liver consists of several components

  1. Bile canaliculi
    
  1. Sinusoids of the liver. 
    
  1. Hepatocytes.
    

Portal lobule

Acinus liver

Hepatic lobules

Nursing Evaluation/Documentation of Cirrhosis

Hypervolemia

Imbalanced Nutrition

Risk for Bleeding related to hematemesis and variceal esophagea

Objective

Analisis

Subjective

Planning

Subjective

Objective

Analisis

Planning

Planning

Analisis

Subjective

Planning

The patient feels better and is able to identify the cause of fluid overload, as well as how to deal with it

The patient's fluid balance is balanced as seen from stable fluid volume, balanced intake and output, stable body weight, normal vital signs, and absence of edema/ascites

Client problems can be resolved by achieving fluid balance

Monitor patient condition and ensure balanced intake/output

  1. The patient says his appetite has increased
    
  1. The patient is able to finish the food without regurgitating it
    
  1. The patient can swallow food well
    
  1. Lab results on normal hb, platelets, erythrocytes and albumin
    
  1. The patient's BB returns to normal
    
  1. The patient's BMI is within the normal range
    
  1. The patient's caloric needs are fulfilled
    

The interpretation of subjective and objective data will assess the extent to which the objectives that have been set in the nursing plan are achieved

Nursing planning that will be continued, stopped, modified, or supplemented from a predetermined nursing action plan

  1. Complaints of having difficulty defecating are reduced and the patient is able to take actions to reduce constipation such as increasing fluid intake and dietary fiber
    
  2. Patients at risk of bleeding take precautions to prevent tissue trauma or disruption of the normal clotting mechanism
    
  1. Lab results in the form of coagulation status and risk of bleeding
  1. Hgb and Hct levels, if you experience a decrease in Hgb and Hct levels it can be an early indicator of bleeding.
  1. Signs of risk of bleeding symptoms in the form of hypotension and tachycardia

The client's problem can be overcome if risk detection and control of bleeding risk is achieved.

Action plans to be continued, stopped, modified, or added to the predetermined action plans, for example blood product transfusion planning if needed


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