Liver Abscess - 7 Nursing Diagnosis, Interventions and Evaluation

Nursing Diagnosis, Interventions and Evaluation for Liver Abscess

1. Breathing pattern, ineffective related to Neuromuscular, imbalance perceptual / cognitive.

Goal : normal breathing pattern / effective and free from signs of cyanosis or hypoxia .

Intervention :

• Maintain the patient's airway by tilting the head.
• Auscultation of breath sounds.
• Observation of the frequency and depth of breathing, the muscles use the respirator.
• Monitor vital signs continuously.
• Do the motion as soon as possible.
• Observation of the excess.
• Do suction mucus when necessary.
• Provide supplemental oxygen as needed.
• Give treatment as instructed.

2. Disturbed Sensory Perception : the process of thought related to chemical changes : the use of pharmaceutical drugs.

Goal : increasing the level of awareness

Intervention :

• Orient the patient back continuously after coming out of the influence of anesthesia.
• Talk with the patient in a clear voice and normal.
• Minimize negative discussion.
• Use the pads on the edge, do binding if necessary.
• Observations of the existence of hallucinations, depression and others.
• Maintain a calm and comfortable environment.

3. Fluid Volume Deficit, Risk for oral fluid intake restriction (process / medical procedure / nausea).

Goal : there is adequate fluid balance .

Intervention :

• Measure and record the input and output.
• Assess urinary spending, especially for the type of surgical procedure performed.
• Monitor vital signs.
• Note the emergence of nausea / vomiting, history of motion sickness.
• Check the pads, appliance drein at regular intervals , examine the wound for swelling.
• Give parenteral fluids, blood products and / or plasma expanders as directed. Level IV speed if necessary.
• Give back oral intake gradually as directed.
• Give antiemetics as needed.

4. Pain (acute) related to disorders of the skin, tissue, and muscle integrity.

Goal : pain has been controlled / eliminated, the client can rest and activity according to ability.

Intervention :

• Assess pain scale, intensity, and frequency.
• Evaluation of pain on a regular basis.
• Assess vital signs.
• Assess the cause of the discomfort that may be appropriate operating procedures.
• Put repositioning as directed.
• Encourage use of relaxation techniques.
• Give medicines as directed.

5. Impaired Skin Integrity related to the interrupt mechanism of the skin / tissue.

Goal : to improve the metabolic action shows.

Intervention :

• Review the functional capabilities and circumstances.
• Place the client in a particular position.
• Keep the body well-being functionally.
• Help or actions to perform range of motion exercises.
• Give skin care carefully.
• Monitor urine output.

6. Risk for infection related to an operating wounds and invasive procedures.

Goal : There are no signs and symptoms of infection

Intervention :

• Provide anti-septic and aseptic care, maintain good hand washing.
• Observations damaged skin area (stitches) attached regions invasive tool.
• Monitor the entire body on a regular basis, record the presence of fever, chills, and diaphoresis.
• Keep an eye or the number of visitors.
• Give antibiotics as indicated.

7. Disturbed Sleep Pattern related to the disease process, the effects of hospitalization, changes in the environment.

Goal : resting needs can be met

Intervention :

• Assess the client's ability and sleeping habits.
• Provide a comfortable bed with a few personal belongings. Example : pillows, bolsters.
• Suggest to light activity.
• Suggest to take action relaxation.
• Encourage the family to always accompany.
• Supervise and limit the number of visitors.

8. Knowledge deficit (learning need) regarding condition / situation, prognosis, treatment needs.

Goal : Declare, understanding of disease processes / pragnosis.

Intervention :

• Revisit surgery / special procedures performed and on future expectations.
• Discuss drug therapy , including the use of a prescription.
• Identification of specific activity limitations.
• Schedule an adequate period of rest.
• Emphasize the importance of further visits.
• Involve famous people in the teaching program. Provide written instructions / teaching materials.
• Repeat the importance of diet and fluid intake adequate nutrition.

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Nursing Care Plan for Liver Abscess

Anatomy and Physiology of the Liver

The liver is the largest gland in the body, the average weight of 1,500 grams. 2 % of normal weight adults. The liver has two lobes that left and right. Each lobe of the liver is divided into structures called lobules, which is a microscopy unit and functional organ. The human liver has a maximum of 100,000 lobules. Between plates of liver cells are capillaries called sinusoids. Sinusoid limited by phagocytic cells and Kupffer cells. Kupffer cell function is to engulf bacteria and other foreign substances in the blood. (Sylvia a. Price, 2006).

The liver has two sources of blood supply , of the gastrointestinal tract and spleen through the hepatic portal vein and from the aorta through hepatic artery. About one-third of the incoming blood is arterial blood and two-thirds is the portal venous blood. The total volume of blood passing through the liver every minute was 1,500 ml. (Sylvia a. Price, 2006).

The liver is the largest and most important metabolic organ in the body. These organs perform a variety of functions, include the following :

1. Processing metabolic major nutrients (carbohydrates, fats, proteins) after absorption is the digestive tract.
2. Detoxification or degradation of residual substances and hormones as well as drugs and other foreign compounds.
3. Synthesis of plasma proteins, including proteins that are essential for blood clotting, as well as to transport thyroid hormones, steroids and cholesterol in the blood.
4. Deviations of glycogen, fat, iron, copper, and many vitamins.
5. The activation of vitamin D.
6. Spending bacteria from the red blood cells are worn out due to the resident macrophages.
7. Excretion of cholesterol and bilirubin (Sherwood, 2001)

Definition of Liver Abscess

Liver abscess is a form of infection in the liver caused by a bacterial infection, parasites , fungi and sterile necrosis originating from the gastrointestinal tract characterized by the process of suppuration with the formation of pus in the liver parenchyma (Aru W Sudoyo, 2006).

An abscess is a collection of pus fluid thick, yellowish caused by bacterial, protozoal or fungal invasion into the tissues of the body. Abscesses may occur in the skin, gums, bones, and organs such as the liver, lungs, and even the brain, an area that occurred abscess red and puffy, there is usually a sensation of pain and local heat (Microsoft Encarta Reference Library, 2004).



Causes

Liver abscess is generally divided into two, namely ; amebic liver abscess and pyogenic liver abscess.

a. Amebic liver abscess
Obtained several species of amoeba that can live as a non-pathogenic parasite in the mouth and intestines, but only Entamoeba histolytica that can cause disease. Only some individuals infected with Entamoeba histolytica, which gives the symptoms of invasive, so it is thought there are two types of E. histolytica, namely ; pathogenic and non- pathogenic strain. Variations in the virulence of these strains differ based on its ability to cause lesions in the liver (Aru W Sudoyo , 2006).

E.histolytica in the stool can be found in two forms: vegetative or trophozoite and cyst forms that can survive outside the human body. Mature cyst size 10-20 microns, resistant to dry and acidic atmosphere. Forms tropozoit will die in dry atmosphere and acid. Large trophozoite very active, capable of consuming erythrocytes , which contains protease ; hyaluronidase and mucopolysaccharidase capable of resulting in tissue destruction.

b Pyogenic liver abscess
The infection is mainly caused by gram- negative bacteria and the most common cause is E. coli . Moreover, the cause is Streptococcus faecalis also, Proteus vulgaris, and Salmonellla Typhi. Can also anaerobic bacteria such as Bacteroides, aero bacteria, actinomicosis, and anaerobic streptococci . Necessary for the finding of blood culture, pus, bile, and swabs in anaerobic or aerobic (Aru W Sudoyo, 2006).



Signs and Symptoms

Initial complaint : fever / chills, abdominal pain, anorexia / malaise, nausea / vomiting, weight loss, night sweat, diarrhea, fever (temperature greater than 38°), hepatomegaly, right upper quadrant tenderness, jaundice, ascites, and sepsis the cause of death. (Cameron 1997)

An abscess is the last stage of a tissue infection that begins with a process called inflammation.
Initially, such as bacteria activate the immune system, several events occur :

1. Blood flow to the area increases.
2. The temperature of the area increases due to the increased blood supply.
3. The area swells due to the accumulation of water, blood, and other fluids.
4. It turns red.
5. It hurts, because of irritation from the swelling and the chemical activity.
6. The four signs ; heat, swelling, redness, and pain - the characteristics of inflammation.

Diagnostic Examination

According to Julius, the science of diseases in Volume I, (1998). Investigations among others ;
1. Laboratory
To determine the hematologic abnormalities include hemoglobin, leukocytes, and liver function examination.
2. chest x-ray
Can be found in the form of the right diaphragm, decreased movement of the diaphragm, pleural effusion, lung collapse and lung abscess.
3. Plain abdominal X-ray
Abnormalities may include hepatomegaly, ileus picture, picture of free air above the liver.
4. Ultrasonography
Detecting abnormalities of biliary tract and diaphragm.
5. Tomography
See abnormalities in the posterior and superior , but can not see the integrity of the diaphragm.
6. Serology
Shows a high sensitivity to germs.



Nursing Diagnosis for Liver Abscess

According Doenges, EM (2000), nursing diagnoses of patients with liver abscess include:

1. Breathing pattern, ineffective related to Neuromuscular, imbalance perceptual / cognitive.
2. Disturbed Sensory Perception : the process of thought related to chemical changes : the use of pharmaceutical drugs.
3. Fluid Volume Deficit, Risk for oral fluid intake restriction (process / medical procedure / nausea).
4. Pain (acute) related to disorders of the skin, tissue, and muscle integrity.
5. Impaired Skin Integrity related to the interrupt mechanism of the skin / tissue.
6. Risk for infection related to an operating wounds and invasive procedures.
7. Disturbed Sleep Pattern related to the disease process, the effects of hospitalization, changes in the environment.
8. Knowledge deficit (learning need) regarding condition / situation, prognosis, treatment needs.

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