:Nursing Diagnosis

Risk for infection related to surgical procedure

:Nursing Intervention
Assess vital signs, surgery site , close monitoring *
of sings and symptoms of rejection
Frequent suction as indicated and care of chest *
tube if present
check dressing frequently *
Change position every 2 hours *
Monitor urine output hourly ; maintain careful*
.intake and output records
*.Weigh daily
Monitor for signs of active bleeding, including*
excess drainage
Monitor serum electrolytes and laboratory values*
related to
blood coagulation, liver function, and renal
.function
*.Monitor neurologic status

Encourage pt. to use spirometer *

Assist pt. to get out of bed *
Encourage pt. to participate in self-care *
procedure to decrease complication of immobility

:Provide discharge teaching*

a. Teach how to reduce risk of infection, and signs
of infection
.to report
b. Instruct to recognize and report signs of organ
rejection
.
c. Discuss all medications, including their purpose,
,schedule
adverse effects, and potential long-term effects.
Stress the
importance of complying with all prescribed
medications
and postoperative precautions

Give them written and verbal instruction about how

and when to take medication and problem that
require consultation
d. Discuss possible changes in body image and
psychologic
responses to receiving a transplanted organ

f. Stress importance of continued follow-up with

.transplant team and primary care provider

:Evaluation
Pt. remain free of infection, as evidenced by normal WBC
count, temp < 100 F, and absence of purulent drainage
.from incisions
 :Nursing Diagnosis
Anxiety related to surgical procedure as evidenced
by verbalization from the patient and patient is
noncompliance

:Nursing Intervention

Assess pt. for signs and symptoms of fear and.1

anxiety
:Implement measures to reduce anxiety.2
a. provide care in a calm, supportive,
confident manner
b. orient pt.'s to environment, equipment, and
;routines

c. Assure pt. that staff members are nearby;

 . respond to call signal as soon as possible
d. Encourage verbalization of fear and anxiety;
. provide feedback
. e. explain all diagnostic tests
f. Reinforce physician's explanations and
.clarify
g. Initiate preoperative teaching if
h. provide a calm, restful environment
i. Instruct client in relaxation techniques and
encourage participation in diversional
activities
j. Provide information based on current needs
of client at a level he/she can understand;
encourage questions and clarification of
information provided
k. Allow pt. to discuss concerns about future
lifestyle and roles

l. provide emotional support and reassurance during the

.procedure

:Evaluation
The pt .experienced a reduction in fear and anxiety
:as evidenced by

verbalization of feeling less anxious .1

usual sleep pattern .2
relaxed facial expression and body movements .3
stable vital signs .4
Signs and Symptoms of Liver Rejection
Fever over 38°C or 100.4°F
Fatigue
(Jaundice (yellowing of skin or eyes
Darkening of urine
Clay-colored stools
Pain over liver