CARE PLAN ON

“Acute chronic liver failure, Hepatitis A related with Post Live

Donor Liver Transplant.”

Submitted to: Submitted by:

Ma’am Madhavi Verma TS Rican

Reader M.Sc. Nursing 1ST Year

CON, ILBS CON

DATE OF SUBMISSION : 11/02/2020

1
INTRODUCTION ABOUT SELF
I myself TS Rican student of M.Sc. Nursing 1st year studied at College of Nursing, ILBS posted in Transplant ICU from 9/02/2020 to
14/02/2020 and will be taking care of Miss Vriti Kishor with the diagnosis of Acute liver failure HAV related with Post Live donor liver
transplant for three days under the supervision of Ma’am Madhavi Verma Reader of CON, ILBS.

INTRODUCTION ABOUT THE CLIENT

Ms Vriti Kishor 19 years old admitted in TICU on 28-01-2020 at ILBS, with the complaint of nausea , vomiting also associated with yellowish
discolouration of sclera and urine which is insidious in onset and gradually progressive for the past 3 months. She also admitted in Banaras
Hindu University, Hospital in the month of October 2019, with the complaint of nausea and vomiting for 2 weeks and found out that, patient is
suffering from jaundice and hepatitis A virus since then she was on medication for 3 months and the same symptoms started again so, she have
to admitted at ILBS for further treatment.

REASON FOR SELECTING THIS TOPIC FOR CARE NOTE

I have chosen this case since live donor liver transplant among young age is very rare in India, and also I want to learn more about the disease
condition, nursing care and its medication.

INFORMANT
Information was collected from the father also from the patient file.

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SOCIO DEMOGRAPHIC PROFILE
Name – Ms Vriti Kishor

Age – 19 years

Gender - Female

Current address- Chandauli Uttar Pradesh, India

Date of admission- 28-01-2020

Diagnosis- Acute liver failure related HAV with post LDLT.

Treating physician/surgeon- Doctor Viniyendra Pamecha

Surgery undergone with date- Live donor liver transplant on 29-01-2020.

CHIEF COMPLAINTS
Miss vriti admitted with the complain of

• Nausea 3 months which is insidious in onset gradually progressive

• Vomiting clear colour in nature no blood and foul smell present, which is sudden in onset and occurs alternately for the past 3 months
and usually relived by medication.
• Yellowish discolouration of sclera and urine for 3 months
• Loss of appetite and weakness for 1 month.

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HISTORY OF PRESENT ILLNESS
Miss vriti kishor 19 years old female patient admitted at TICU ILBS, with chief complaints as mention above, after undergoing various
investigation she was diagnose as Acute liver failure and she have to undergone emergency liver transplant on 29-01-2020 and her donor was
father itself. Presently she is on ventilator SIMV mode with tracheostomy and nasogastric tube in situ, also present of left and right drain with
foley cather in situ. Currently patients is suffering from mild fever and diarrhoea and she’s under proper observation and treatment, edema
present over upper and lower limbs and ecchymosis present over the left arms, there is no other sign of complication present till now, patient is
very cooperative and physician are for planning to start soft diet and removal of drains. Everyday she is assist for ambulation and daily
physiotherapy of limbs and chest is given to the patient. whereas there is no sign of graft rejection till now.

PAST HEALTH HISTORY

According to the information given by the parents she have past medical illness of jaundice for the past 3 months and others medical history such
as tuberculosis, hypertension, diabetics and malaria are not present.

PAST SURGICAL HISTORY

Patient does not have any surgical history in the past.

PERSONAL HISTORY
Diet and nutrition - patient is non- vegetarian and her staple food are rice/roti and curry, and patient have food twice in a day i. e lunch and
dinner. The patient has all the seasonal vegetables and fruits available in the market. And presently patient is on liquid diet, feeding through
nasogastric tube every 2nd hourly.

Elimination pattern- the patient has regular pattern of elimination, no constipation and loose stool as informed by the patient father before the
admission. Following the post-operative procedure she have loose stool for 3 days and absent of bloody stool and she’s on medication.

Sleep pattern – patient sleep 7 hours at night time and 3 hours nap in the evening. Whereas after admission in the hospital patient has difficulty
in sleeping at night time due to her disease condition and secretion through the tracheostomy site for which most of the time patient take a nap
in the morning and evening .

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Activity and rest pattern- before she was admitted in the hospital she help household choir and in the afternoon she usually take a nap.

Substance use- patient does not use any drugs.

Leisure activities- the patient spent her leisure time watching movies and reading.

Occupational history- My patient is in her final year in psychology speciality.

Medication history – patient have jaundice 3 months back and does not have any medical history in the past such as tuberculosis, cardiac
disorders, and genetic disorder.

Allergic reaction- the client does not have any allergic reaction

Immunization history – patient hast received all the immunization which is required in each months and years.

SOCIAL HISTORY
According to the information provided by the patient father , she belong to Hindu and middle class family and was born in Chandauli Uttar
Pradesh , and studied in physchology final year , she use to be frankly with everyone, and also have good relationship and good performance in
the college.

FAMILY HISTORY
Type of family- nuclear family

Total number of family- the family members are 4 in numbers.

Number of dependents- 3 members are dependent on father.

Total family income- Rs 35-38 thousand per monthly

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Family pedigree-

Mr Suresh kishor 42 years (Father) Mrs. Lokhi Bibi 36years (Mother)

Mr Mohan 22 Years (Brother) Miss Vriti 19 years (Sister).

Relationship with
Name of members Age/sex Education Occupation Health status
clients
1. Mr.Suresh Father 42 years /male B.A passed Govt. Employer Post-Liver donor
Kishor

2. Mrs.Lokhi Mother 36 years/ female Class 9 Homemaker Healthy

bibi

3. Mr Mohan Brother 22 years/male Graduate Student Healthy

4. Miss Vriti Patient 19 years / female Graduation final year Student ACLF & HAV
Kishor related with post
LDLT.

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CURRENT HEALTH STATUS
Miss Vriti undergone Liver donor liver transplant on 28-01-2020, and admitted to Transplant ICU with present of left and right drain,
tracheostomy in-situ and she is on ventilator. Since, she cannot eat orally nasogastric tube was place for getting adequate amount of nutrition,
due to post surgery edema is present over the lower and upper limbs, with ecchymosis over the left arm, her bilirubin decrease from 10.9 md/dl
to 6.5 mg/dl and also she started to have soft diet and she longer don’t have fever and diarrhoea whereas she can sleep well during night and
there is no sign of infection presently.

VITAL SIGNS

Day 1
Temperature - 99.40 Fahrenheit

Pulse- 86/min

Respiration- 26/min

Blood pressure- 123/80 mmHg

Spo2- 100%

Day 2
Temperature – 98.5ºF

Pulse – 86/min

Respiration – 24/min

Blood pressure – 133/80mmHg

Spo2 - 99%
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Day 3
Temperature – 98.60 F

Pulse – 82/min

Respiration – 24/min

Blood pressured- 136/80 mmHg

Spo2 – 100%

PHYSICAL EXAMINATION
General appearance

• Level of consciousness : conscious and obey command.

• Hygiene : well maintained
• Activity: affected due to edema over the lower limbs patient can partially move her limbs and supported during ambulation.
• Posture and gait : assistance required during changing position and ambulation
• Nourishment: adequate
• Weight : 62 kg

Skin and nails

• Colours : pale and ecchymosis present over the left hand

• Texture : skin is dry and peel off skin is present
• Temperature : 99.4ºF
• Lesions : surgical wound present in the abdomen
• Clubbing : absent
• Koilonychias : absent

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 • Cyanosis : not present
• Capillary refill time: 2 second

Head

• Colour of hair: dark in colour

• Shape of skull: symmetry
• Scalp : neglected
• Pediculosis : not present
• Texture : rough

Face

• Face: absent of dropping of face, no scars present, moles present on the cheek, crack lips and dry skin present.
• Oedema: slightly present
• Hydration: poor, dull skin appearance.
• Any abnormality : normal

Eye

• Vision : patient can see with the both eyes

• Eyes brows: eye brow are normal and symmetrical
• Conjunctiva: pale in colour
• Sclera: sclera are normal
• Corneal reflex: normal
• PERRLA: pupils are round and reactive bilaterally to light and accommodation, no dilation seen.

Ear

• Hearing : normal

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 • Tympanic membrane: no perforation and lesions are seen
• Discharge : there is no discharge present
• Absent of low set ear
• Cartilage well form bilaterally.

Nose

• Nostrils : no discharge and flaring of nose is seen, absent of epistaxis

• Nasal septal deviation: no deviation present
• Sinuses : no sinusitis present

Mouth / Pharynx

• Lips : dry and crack is present

• Odour : no foul smell present
• Mucous membrane and gums : absent of ulcer and gingivitis
• Tongue : white coated but no lesions
• Tonsils : no inflammation present
• Gums : normal
• Dental caries : absent
• Gag reflex : present
• Lymphadenopathy is not present in the pharynx.

Neck

• Nuchal rigidity: not present

• Lymph modes: no lymphadenopathy present in the neck

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 • Thyroid gland : normal
• Injury of wound present in the neck
• Tracheostomy present.

Chest

Respiratory system:-

• Inspection : symmetrical and normal

• Palpation : pain radiating from surgical site.
• Barrel chest : absent
• Breathing pattern : 26 breaths / minute
• Percussion : normal
• Auscultation : S1 and S2 heard

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Cardiovascular system

• Inspection : no abnormality present

• Palpation : cannot palpate due to pain over the abdomen.
• Auscultation : S1 and S2 heard
• Heart rate : 89 beat/min
• Pain : pain radiate from the surgical site

Abdomen

• Inspection : wound present over the abdomen, reddish bloody discharge is collected over the drain and no sign of infection.
• Auscultation : bowel sound present which consist of rumbling and gurgles sound at 10-30 bowel sounds occurring every 5- 35 per
minute.
• Percussion : normal
• Palpation : cannot cannot due to pain

Genitalia

• Abnormal discharges : absent

• STDS: absent
• Any enlargement : not present
• Haemorrhoids : absent
• Foley catheter is present

Extremities

• Movement : movement is affected over the lower limb

• Tremors : absent

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 • Edema :present
• Reflexes ( biceps , triceps, patellar, ankle and planter): present over the lower limbs and right arm but left arm cannot be assessed due to
splint .
• Varicose vein: absent

Spine

• Spina bifida: absent

• Curves : lordosis ,kyphosis , lordosis ,scoliosis are not present in patient

Musculoskeletal system

Reflexes

• Biceps : forearm flex is present in the right arm but left arm cannot be assessed due to present of splint.
• Triceps : extension of elbow present over the right arm, but left arm cannot be assessed
• Patellar: kicking movement present in both legs which is normal.
• Ankle : jerking of the foot is present towards the its planter surface.
• Plantar reflexes : there is present of toe flexion which is normal.
• Test for sensation :present in face whereas in both upper and lower limbs

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INVESTIGATION
LABORATORY INVESTIGATION

Serial SPECIMEN NAME OF THE Client value NORMAL VALUE REMARKS

no. INVESTIGATION Day 1 Day 2 Day 3
10-2-20 6/11/19 7/11/19
1 BLOOD HB 9.4 8.4 7.3 12- 16 gm./dl anaemia
TLC 18.2 2.1 15 4000-11000 cell high
NEUTROPHILS 91.1 86.8 84.0 40%-60% high
LYMPHOCYTES 6.9 10.5 12.8 20%-40% low
MONOCYTES 1.2 1.9 1.7 2%-8% low
EOSINOPHIL 0.3 0.5 1.2 1.5×109/L low
PLATELETS 209 224 208 1.5-4.5 × 105 ML normal
PT/INR 14.8/1.24 15.2/1.2 14.9/1.25 11-13.5 sec/0.8-1-1sec high
BU 36.6 36.38 38.52 2.5-7.1 mmol/L high
CREATININE 0.3 0.3 0.3 0.6-1.2 mg low
SODIUM 134 134 135 135-145 mEq/L normal
POTASSIUM 4.1 4.2 4.1 3.5-5.0 mEq/L normal
CHLORINE 104.3 104.8 99.9 96-106 mEq/L normal
CALCIUM 8.3 8.3 8.4 8.6-10.2mg/dl normal
MAGNESIUM 1.48 1.72 1.31 1.5-2.5 mEq/L low
S.BILIRUBIN(T/D/I) (9.6/6.2/3.4) (9.8/6.1/3.7) 7.8/4.6/8.2 0-0.4/ 0.2 –1.2 mg/dl high
AST 85 64 57 10-14 units high
ALT 230 213 147 7-56 units high
SAP 140 145 133 66.12 mg/ml high
GGTP 112 105 82 9-48 U/L high
T.POTEIN 4.6 4.5 4.5 6-8.3 g/dl low
ALBUMIN 2.7 2.6 2.5 3.4 – 5.4 g/dl low
GLOBULIN 1.9 1.9 1.2 2.0-3.5 g/dl low
TAC TEST 4.5 4.6 4.6 0.5-15.0 ng/dl normal

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CULTURE REPORT(7-02-2020) FOR MICROBIOLOGY

1. Nature of specimen – Tracheal Aspiration

Organism isolated – Klebsiella pneumonia

Resistant’s drugs are:

• Injection Tazact
• Injection Ceftazidime
• Injection Cefoperazone
• Injection Cefepime
• Injection Imipenem
• Injection Meropenem
• Injection Amikacin
• Injection Gentamicin
• Injection Levofloxacin
• Injection Colistin
• Injection Fosfomycin

Sensitive to: Injection Trimethoprim and Injection Ceftriaxone + Sulbactum+ EDTA

2. Aerobic Culture and sensitivity blood

Organism isolated: Klebsiella pneumonia

Resistant’s drugs are:

• Injection Tazact
• Injection Ceftazidime
• Injection Cefoperazone
• Injection Cefepime

15
 • Injection Imipenem
• Injection Meropenem
• Injection Amikacin
• Injection Gentamicin
• Injection Levofloxacin
• Injection Colistin
• Injection Fosfomycin

Sensitive to:Injection Ceftriaxone + Sulbactum+ EDTA

ARTERIAL BLOOD GAS REPORT :

➢ Day 1(10/02/2020)

PH- 7.49 mmHg

PCO2- 32.5 mmHg

HC03- 25.0 mmol/L

➢ Day 2(11/02/2020)

PH- 7.478 mmHg

PCO2- 34.8 mmHg

HCO3- 26.5 mmol/L

➢ Day 3(12/02/2020)

PH- 7.45 mmHg

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PCO2- 34.9 mmHg

HCO3- 25.5 mmol/L

DOPLLER ULTRASOUND REPORT:

Date Date Date

Hepatic artery PSV-3.4 PSV-3.5 PSV-45
RI- 0.93 RI- 0.66 RI-0.67
Main portal vein PSV- 45 PSV- 35 PSV- 41
FV- 2.4 RI- 1.9 RI- 1.31
Hepatic veins IVC- 15.3 IVC- 15.2 IVC- 22
Fusion Minimal minimal minimal
Ascites not present not present not present

17
 3

TREATMENT
Trade Dose/rout Frequen Action Indication Indicati Contraindi Side effects Monitorin Nurses
name/pharmacol e cy on my cation g responsibility
ogical name patient paramete
rs
Injection Iv 500 mg B.D Inhibits cell wall Intra- Post Hypersensit Headache Vital signs Assess the patient
Doripenem formation abdominal LDLT ivity to Nausea are for infection.
infection, wound doripenem Anemia and recorded.
UTI & present. increase T- 99.4ºF Obtain specimen
pyelonephri liver P-78/min for culture
tis. enzyme RR-
24/MIN Observe patient
BP-122/85 for sign and
mmHg symptoms of
SPO2- anaphylaxis
100%
Caution to notify
the nurse if any
reaction occurs.

Tablet 200mg BD Inhibits synthesis Oropharyng Tracheos Renal Headache Vitals Asess infected
fluconazole of fungal sterols, eal tomy and Impairment DizzinessA Checked area and monitor
a necessary candiasis nasogastr bdomen And CSF cultures
component of the Peritonitis ic tube Hypersensit Discomfort Recorded before and during
cell membrane. Cryptococc in- ivity. Nausea T-98 0 F therapy
al situ.(to Vomiting P- 82/min
meningitis prevent hypokalemi RR- Specimen for
UTI. from a 24/min culture
fungal SP02-

18
 colonizat 100% Monitor BUN
ion). nand serum
Diarrhoe creatinine
a
Monitor liver
function test.

Instruct to notify
physician if any
reaction took
place.
Injection IV 1gm. BD Bind to bacterial Respiratory Tissue Hypersensit Headache Vitals Assess for vital
ceftriaxone / cell wall tract breakdo ivity to Diarrhea sign are sign, urine ,
monocef membrane, infection, wn near penicillin, Nausea monitored stool,WBC, at the
causing cell death Skin the drain Hyperbilir- Cramps T-99.9ºF beginning of
infection insertion. ubenemic Hematuria P-86/min therapy
Intra- neonates. Haemolytic R-26/min
abdominal Inborn error anaemia BP- Obtain specimen
Infection, of 100/80mm for culture and
otitis media, metabolism. Hg sensitivity before
bone (Day 1) initiating therapy.
infection.
Observe for sign
and symptoms
for anaphylaxis.
Monitor prom
thrombin time
and assess patient
for bleeding
daily.

Assess for any

19
 allergic reaction
during the
treatment.
Capsule prograf 5 mg OD Inhibit T- Prevention Post Hypersensit Agitation Vitals Assess for
lymphocytes of organ LDLT ivity Anxiety Sign symptoms of
activation rejection in Breastfeedi Confusion checked posterior
patient who ng Depression Recorded. reversible
have Renal Emotional T- 980F emcephalopathy
undergone impairment lability P- 78/min Seizures and
allogenic Hyperkalem Hallucinatio RR- visual
liver,kidney ia n 20/min disturbance
or heart Psychosis BP-
transplant. Vomiting 122/68mm Monitor blood
Nephrotoxic Hg. pressure
ity SP02_100
Pruritis and % Assess skin
rashes lesions before
and after therapy

Daily tacrolimus
blood level test

History collected during 3 days of care plan are:

Day 1
I met my patient on day 1 of my care plan , she was on ventilator with tracheostomy in situ and was conscious and obeys the commands, patient
look fatigue and tired during routine care , hemodynamic parameters was monitored and found that she’s having fever and for two days loose

20
stool was passed 3 to 4 times a day. Physician plan for removal of both the left and right drain within days. Blood culture, urine culture , Drain
culture was send for investigation.

Day 2
On the second day, patient fever was normal and also she doesn’t have loose stool anymore. Right drain was removed. Edema also reduced then
before, patient is assisted for ambulation, she is having trouble sleep during time and physician has change from liquid to soft diet.

Day 3
Patient blood and urine culture has come and found to be present of klebseilla pneumonia and only sensitive to Ceftriazone and sulbactam.
Patient has eat soft diet and also secretion also reduced and her hemodynamic parameters also stable. Physician are planning to decannulate the
tracheostomy tube.

List of problem identified are:-

• Ineffective airway clearance
• Ineffective airway breathing
• Poor nutrition intake
• Sleep disturbance
• Fever
• Diarrhoea
• Edema over the upper and lower limbs
• Pain
• Difficulty in mobilization

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List of Nursing diagnosis according to patient priority (NANDA)

Day1

• Ineffective airway clearance related to tracheostomy as evidence excessive productive secretion and presence of hoarseness sound.
• Ineffective airway breathing related to decrease chest expansion secondary to post - operative procedure as evidenced by changes in
respiratory rate and depth
• Acute pain related post-surgical procedure as evidenced by grimace facial expression.
• Risk for deficient fluid volume related to diarrhoea as evidenced by decrease urine output, dry skin

Day 2

• Disturbed sleep pattern related to burn injury pain as evidenced by sleepiness during the day and general tiredness
• Hyperthermia related to illness or tissue trauma as evidenced by increase body temperature, flushed skin, restless
• Imbalanced nutrition less then body requirement related to anorexia evidenced by weakness and fatigue.

Day 3

• Risk for organ rejection related to post liver transplant.

• Risk for infection related to post Liver transplant and tracheostomy insitu.

22
 NURSING CARE PLAN
ASSESSMENT DIAGNOSIS GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION
Objective data: Ineffective airway Patient will be Monitor vital sign To know baseline Vitals sign are checked Patient relieved
Patient look tired, clearance related able to clear data of the patient. and monitored. from productive
cough with unable to tracheostomy as secretion excessive
to produce evidence within a secretion.
secretion. excessive week. Provide To moisten the Asthalin and doulin
productive nebulization secretion and will be nebulization given to the
secretion and easier to produce and patient. Patient breathing
presence of prevent from dry pattern has
hoarseness sound. cough. improved.

Provide semi To expand the lung Semi fowler position

fowler position. expansion. provided given to the
patient.

Provide suctioning. To clear the Suction is given to the

excessive secretion patient.
and improve
breathing pattern.

23
Objective data:
Patient is supported Ineffective airway Patient Monitor vitals sign To know the Vitals sign are checked Patient breathing
by ventilator SIMV breathing related breathing baseline data of the and recorded. breathing has
mode and to decrease chest pattern will be patient. improved SPO2
occasionally there is expansion improved. 100%.
changes in secondary to post
respiratory rate and - operative Provide semi - To expand the chest Semi-fowler position. Decrease use of
depth. procedure as fowler position. expansion. accessory
evidenced by muscles.
changes in
respiratory rate To monitor the
and depth Monitor ABG oxygenation and ABG is done for the
analysis ventilator status. patients.

To maintain the
Monitor the pre-set hemodynamic status Pre-set the ventilator
mode of ventilator. of the patient. mode as advised by the
physician.

The incapability to
Assess ability to mobilize secretions Patient ability to mobilize
mobilize secretions may contribute to secretion is assessed.
change in breathing
pattern.

Beta-adrenergic
Provide respiratory agonist medications Administered medication

24
Objective data: Acute pain related Patient will be Asses the pain To identify the Patient pain level is The patient feel
Patient look restless, post-surgical experiencing level, noting baseline data of the assessed and the pain better after
with grimace facial procedure as reduction in location and patient and treat score is 5 out of 10. administering
expression during evidenced by pain within a character and accordingly. pain medication.
nursing procedure grimace facial week. intensity (0–10
Pain score is 5 out expression scale)by using
of 10. wong baker face Pain score is
visual scale. reduced from 5
to 3.

Provide Maintaining a good

comfortable position will reduce Blanket and wrinkle free
environment and the discomfort of the bed is provided.
position to the patient.
patient.

To change position Movement and Encouraged the patient to

frequently exercise reduce joint follow the instruction
and assist with stiffness and muscle given.
active and passive fatigue, but type of
ROM as advice by exercise depends on
the physician. Severity of the
injured area
Administer Due medication given to
analgesics as Administering the the patient.
advice by the pain medication will
physician. relieve from
discomfort.

25
Objective data Risk for deficient Patient will be Monitor vitals sign. To provide baseline Vital sign are checked and Patient fluid loss
Patient skin look fluid volume able achieved data of the patient recorded will be replaced
dry , decreased skin related to normal fluid for effective nursing Temperature - 99% soon.
and dry mouth diarrhoea as volume as and medical c Respiration-24 /min Urine output is
turgor is present evidenced by required by Provide a guideline Pulse- 83/min improved from
,lethargy. decrease urine the body. to serves as a guide 400ml to 700ml.
output, dry skin to fluid replacement
Total output = needs and assesses
400 ml cardiovascular
response

Monitor urinary Generally, fluid urine output is recorded in

output and specific replacement should the document .
gravity be titrated to ensure Intake = 400ml
average urinary output=300ml
output of 30–50
mL/hr (in the adult).

Weight daily A 15%–20% weight Patient is weight i.e. 62kg

gain can be
anticipated in the
first 72 hr during
fluid replacement.

Monitor laboratory Identifies blood loss Blood is send for

studies: Hb/Hct, or RBC destruction investigation.
electrolytes, and fluid and
random urine electrolyte
sodium replacement needs.
Urine sodium less

26
 than 10 mEq/L
suggests inadequate
fluid resuscitation.

To replace the fluid

Administer fluid loss and balance the Intravenous RL 4ml/hour
and electrolyte as fluid required by the is given.
advice by the body.
physician.

Objective data: Disturbed sleep Patient will Each individual has Patient can rest
Patient look tired all pattern related to improve her Assess the past different sleep Patient sleep pattern is and sleep well as
day, and most of the burn injury pain as sleep pattern sleep pattern of the pattern of sleep. assessed reported from the
time she feel evidenced by .after giving patient such as Information given by staff.
drowsy and lie on sleepiness during nursing duration, position the patient will
the bed. According the day and intervention and external factors provide baseline to
to the nurses records general tiredness for 3 days. affect the sleep improve the Patient 1 glass
patient have pattern. environmental of warm milk
difficulty in falling stimulation before bedtime.
asleep.

Excessive fullness
Encourage the will upset the Patient is given light diet
patient to give stomach and hinder before bed.
small amount of the sleep pattern of
food and avoid the patient. Coffee,
heavy , caffeine, cakes stimulates the
cakes before nervous system, and
bedtime. will interfere patient

27
 ability to relax and
fall asleep.

Patient sleep
In insomnia, stress well after
Encourage for may be relieved by Encouraged the patient for providing
ambulation. providing light ambulation. comfort
exercise measures.

A lot of people sleep

Provide cool, calm better in cool and Cool and calm
environment during calm environment. environment is provided.
bedtime.
L-tryptophan is a
component of milk 1 glass of warm milk is
Provide warm milk which promotes gven.
before bedtime sleep.

Therapeutic position
is one of the Wrinkle free bed is given
Provide effective nursing with comfortable device.
Comfortable care measures , to
position. make the patient
comfortable and can
even reduced the
disease associated
with pain

28
 To provide baseline
Objective data: Hyperthermia Patient fever Monitor vitals sign. data for effective Vital sign are monitored Patient fever has
Patient looked related to skin will reduced nursing and medical and recorded reduced from
weak, with tiredness lesions secondary after 1- 2 care. Temp- 99.4ºF 99.4ºF to 96.7ºF.
facial expression, to burn injury as hours. Pulse – 86/min
sweaty skin evidenced by Respiration- 26/min
appearance. increased body (day 2)
Temperature of temperature,
99.4ºF. flushed skin To reduced the body
Provide cold temperature. Cold compressed is given
compress. to patient.

.
Reduced the fever
by promoting heat Intravenous paracetamol
Administer loss and thus helps 100 ml is given as adviced
antipyretics. reset hypothalamic by the physician.
thermostate.

To replace the fluid

loss during increase Provide 1 glass of water
Provide fluids . body temperature. and administerd
intravenous RL 500ml at a
rate of 4ml / hour .

To identified the
Monitor the culture organism present
and sensitivity of which causes Blood and urine culture
the blood and urine. infection to the and sensitivity has send
body. for investigation.

29
 This will provide
Objective data: Imbalanced Patient will Assess the baseline for planning Nutritional status is Patient appetite
Patient unable to eat nutrition less then improve nutritional status of proper caloric intake assessed. has improved.
soft diet properly body requirement her appetite in the patient. needed by the body.
Patient look weak , related to anorexia 2 day.
thin , dry and pale evidenced by
skin complexion . weakness, fatigue. Heavy intake of
Encourage to eat meal will make him Patient is encouraged to
small frequent more discomfort, eat small frequent meal.
meal. since small frequent
meal lessens the
fullness and prevent
from vomiting.

Oral hygiene
Provide oral promotes the Oral care given
hygiene. appetite and urges to
eat more.

Food rich in proteins

Provide food rich and vitamins help Calm and clean
in proteins and the tissue to heal fast environment is provided.
vitamins. and help the immune
system and act as a
source of energy.

Pleasant
Provide pleasant environment Comfortable position and
environment decrease the stress environment is provided
and more favourable to
to eat.

30
Objective data: To know the
It is found that Risk for infection Risk of Monitor vitals sign baseline data of the Monitored vital sign of the There is no sign
patient culture and related to post infection will patient. patient of infection in
sensitivity results Liver transplant be reduced in Tem- 99.4ºF the lesions.
rule out the and tracheostomy a weeks. Resp -24
presence of insitu. Pulse- 84
klebseilla
pneumonia. And Use of PPE and Dressing with sterile Patient parent’s
also patient look strict aseptic technique reduce the Wound dressing done. has performed
pale and dull. technique during risk of infection and proper hand
Temperature was direct wound care early healing of the washing before
99.40F and provide sterile wound. taking care of
or freshly patient.
laundered bed
linens or gowns.

Sending the To provide baseline Culture swab is send and

culture and data related to rule out the presence of
sensitivity test. infections. klebseilla pneumonia
.

Administer To bind with the Injection ceftriaxone1 gm

antibiotic as bacterial cell wall iv is given.
prescribed by the and causes death.
physician. Also reduced the
infection rate.

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 Proper hand
washing technique To prevent from the Patient attendants
cross infection. instructed to perform
proper hand washing and
also the health care
workers.
Monitor
hemodynamic
Objective data: parameters , To identified the
Patient has Risk for organ Patient risk of baseline data of the Hourly parameters ae Patient fever has
occasionally fever rejection related to organ failure patient. maintained. reduced.
and changes in post liver will be
respiratory rate and transplant. prevent from
depth and sign of specific Provide Hemodynamic
edema over the nursing and immunosuppressant parameters are
limbs. medical care. Drugs. To prevent from the stable.
organ rejection by Capsule prograf 5 mg is
own immune system. given.

Monitor the
laboratory
investigation. To rule rule any
organism causing the Routine investigation is
body to get infected. send.

Administer
antipyretics drugs. To inhibit the
enzyme
Provide cyclooxygenase and Due medication given.
tracheostomy interrupt the
dressing. synthesis of

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 inflammatory
prostaglandins.

To prevent from
harmful colonization Tracheostomy dressing
of organism. done.

PROGRESS REPORT

Day 1(10-02-2020)
I met miss Vriti on 10 of february and introduce myself to her and explain about the care I will taking of her. Patient look exhausted and she
cannot mobilizes well due to edema present. She was having fever on the first day and culture and sensitivity was send fro investigation.

Vitals are checked and recorded

Temperature-99.40F
Respiration – 24/min
Pulse – 84/min
RR- 24/min
• Due medication given to the patient
• Assess in dressing of the wound
• Provide tracheostomy care
• Culture and sensitivity test was send.

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 • Provide DVT stocking to the patient.
• Provided comfortable position to the patient and pillow place under her left arm

Day-2(11/02/2020)

On the next day , patient have episode of diarrhoea passed 3 times a day. Right drain was removed by the physician and also her diet has
change to soft diet.

Temperature – 98.5ºF

Pulse – 86/min

Respiration – 24/min

Blood pressure – 133/80mmHg

Spo2 - 99%

• Vital sign are checked and recorded

• Administer fluids and electrolytes
• Provide ORS water in nasogastric tube.
• Routine laboratory investigation has send
• Provide adequate amount of nutrition
• Encourage to take proper rest

Day-3(13/02/2020)

On the third day patient has improved a lot whereas fever and loose stool also subside. There is no drainage from the drain tube so the physician
have removed the left drain. Edema was subside than before but the patient has difficulty in sleeping during night.

Vitals sign are checked and recorded :

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Temperature – 98.60 F

Pulse – 82/min

Respiration – 24/min

Blood pressured- 136/80 mmHg

Spo2 – 100%

• Patient is encourage not to sleep during day time.

• Provide comfortable position
• Encourage for ambulation
• Maintain safe hand hygiene and sterility during the patient care.

HEALTH EDUCATION :

Diet
• Encourage to consume food adequately.
• Important of oral hygiene has taught to the patient.
• To consume food rich in nutrients
• To avoid spicy food
• To prepare food after washing properly

Physical activity and exercise

• Encourage to go for morning and evening walk

• Advised to avoid sports in public place.
• Encourage the patient to avoid any accident or sharp object
• Attendants are encouraged to assist the patient during range of motion.

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 • Encouraged not to sleep in day time.

Medication

• Encourage the parents to give medication on time and not to skip her medication.
• Taught the patient parents not to give any medication without the physician prescription.
• Taught about the importance of medication.

Prevention from complication

• Encourage the patient parents to come for check-up if any abnormality found in patient body
• To identified any abnormal sign and symptoms
• To check her routine haemoglobin level.
• To take proper medication at the time.
• To inform doctors if there any abnormal sign observed.
• Taught about the complication of post liver transplant.
• To avoid consumption of wine and alchohol

Rehabilitation

• To follow the exercise which physiotherapy has taught.

• Parents and patient should send for family support group to strengthen the family emotion and crisis they have faced earlier.

Home care and follow up

• Encourage to maintain personal hygiene.

• Avoid consumption of alcohol and drugs
• To avoid sedentary lifestyle.

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 • Encourage the patient to come for regular health check-up after the discharges
• To avoid excessive exposure outside the house.
• To avoid come in contact with sick patient.

REFERENCE
• Judith Hopfer Deglin, April Hazard Vellerand, Davis’s Drug Guide for Nurses 12edition , 2010 publisher Robert G.Martone
Page no. 245-246.124.156.,345-348.1219-1222

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