NURSING CARE PLAN

Assessmen t Nursing Background Diagnosis Knowledge Planning 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. Rationale Evaluatio n

Subjective Altered Altered level After two Cue: level of of weeks of madalas consciousn consciousnes nursing siyang ess related s is due to intervention inaatake ng to increase ammonia the patient kombulsyon level of build up in will: tapos pag ammonia the brain, *improve nagsasalita this is in level of siya hindi ko relation to consciousne na hepatic ss from level maintindihan encephalopa 2 as thy. (stuporous) verbalized Ammonia to level 4 by the failed to be (lethargic) relative. converted to *increase urea because the Glasgow Objective of altered coma scale Cues: liver function from 6 to 10*Flapping and damage 12 tremors liver tissue *laboratory *hyperexten mainly results ded wrist fibrosis and within /decerebrate nodule normal level *History of formation in -SGPT-4-36

*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 *Perform full range circulations, maintain of motion on muscle tone and extremities using prevents slow smooth contractures and movements. muscle atrophy. *Observe pressure *To avoid altered areas and provide circulation, loss of meticulous skin care. sensation and pressure sore Dependent formation. *Administer

hepatitis (Jaundice) *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

portal areas and central veins of the liver which is referred as portal cirrhosis.

international unit/l -ALP-30120u/l -SGOT-035u/l -serum ammonia 1080mg/dl

medications and *To improve patients provide treatment as condition. ordered. -injection of -prevent and treat Vitamin K unusual bleeding and low level of clotting -furosemide factor. -treat fluid retention -spironalactone edema and swelling -treat acites and -sorbitol prevents build up of neomycin fluid enema -stimulates bowel -lactulose movement -reduce amount of Collaborative ammonia by ecretion *Follow up monitoring of *To be updated with laboratory and the patients diagnostic results to condition. be referred to the physician. *Inform dietician for *For appropriate diet the food restriction the patient must and diet of the receive. patient. -restrict Na - prevent fluid intake to 500mg accumulation daily -to prevent increase -restrict Protein ammonia build up

intake to 40g daily

that will affect the brain