Anatomy of Hepar
divided
smaller left lobe
large right lobe
Histologically, the liver consists of several components
Bile canaliculi
Sinusoids of the liver.
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
The patient says his appetite has increased
The patient is able to finish the food without regurgitating it
The patient can swallow food well
Lab results on normal hb, platelets, erythrocytes and albumin
The patient's BB returns to normal
The patient's BMI is within the normal range
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
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
Patients at risk of bleeding take precautions to prevent tissue trauma or disruption of the normal clotting mechanism
- Lab results in the form of coagulation status and risk of bleeding
- Hgb and Hct levels, if you experience a decrease in Hgb and Hct levels it can be an early indicator of bleeding.
- 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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