NURSING CARE PLAN

Assessment Subjective Cue: madalas siyang inaatake ng kombulsyon tapos pag nagsasalita siya hindi ko na maintindihan as verbalized by the relative. Objective Cues: *Flapping tremors *hyperextended wrist /decerebrate *Jaundice skin *icteric sclera *GCS -6 -eye opening (2) -motor response(2) -verbal response(2) *stuporous *SGPT-110u/l *ALP-25u/l *SGOT-41u/l *serum ammonia 95mg/dl Nursing Diagnosis Altered level of consciousness related to increase level of ammonia secondary to impaired liver function. Background Knowledge Altered level of consciousness is due to ammonia build up in the brain, this is in relation to hepatic encephalopathy. Ammonia failed to be converted to urea because of altered liver function and damage liver tissue mainly fibrosis and nodule formation in portal areas and central veins of the liver which is referred as portal cirrhosis. Planning After two weeks of nursing intervention the patient will: *improve level of consciousness from level 2 (stuporous) to level 4 (lethargic) *increase the Glasgow coma scale from 6 to 10-12 *laboratory results within normal level -SGPT-4-36 international unit/l -ALP-30-120u/l -SGOT-0-35u/l -serum ammonia 10-80mg/dl Intervention Independent *Monitor Glasgow coma scale and other neurologic assessment every hour and compare findings and report for any changes. *Discuss seizure warning sign and usual seizure pattern to the relatives. *Perform full range of motion on extremities using slow smooth movements. *Observe pressure areas and provide meticulous skin care. Dependent *Administer medications and provide treatment as ordered. -injection of Vitamin K -furosemide -spironalactone -sorbitol neomycin enema -lactulose Collaborative *Follow up monitoring of laboratory and diagnostic results to be referred to the physician. *Inform dietician for the food restriction and diet of the patient. -restrict Na intake to 500mg daily -restrict Protein intake to 40g daily Rationale Evaluation

*To identify changes or improvement in the patients condition particularly the level of consciousness. *To educate them for prevention of injury and complications during seizures. *Enhances circulations, maintain muscle tone and prevents contractures and muscle atrophy. *To avoid altered circulation, loss of sensation and pressure sore formation. *To improve patients condition. -prevent and treat unusual bleeding and low level of clotting factor. -treat fluid retention edema and swelling -treat acites and prevents build up of fluid -stimulates bowel movement -reduce amount of ammonia by ecretion *To be updated with the patients condition. *For appropriate diet the patient must receive. - prevent fluid accumulation -to prevent increase ammonia

build up that will affect the brain