Question

Create a nursing plan of care for patient with high ammonia level.

What would you assess?

What are the goals for the patient?

What nursing interventions are appropriate for this patient?

How would you evaluate the effectiveness of your interventions?

What patient teaching will you include to prevent increase ammonia level and to prevent its complications?

Answer 1

High ammonia levels can be associated with encephalopathy.High levels of ammonia is a recognized cause for encephalopathy.

High ammonia levels can be associated with decompensated liver disease.it is called as hepatic hyper ammonia.There are also a number of cases with non-hepatic causes of hyperammonia.

The main signs and symptoms associated with high ammonia levels are confusion and coma.

other symptoms of high ammonia levels are:

*Lethargy

*Nausea/vomitting

*Inadequate diet

*Ineffective breathing pattern etc

The nursing care plan for high ammonia levels are:

Nursing care plan

1.Acute confusion related to high ammonia levels

Assessment:

*Assess for the level of consciousness

*Asses for the patient orientation and alertness to person,place and time

*Asses for any pain such as head ache(some times due to high ammonia levels there may be a chance of Increased ICP or CNS changes)

Assess the patient blood values

Goals:

To maintain the patient alert and orientation

Interventions:

*Determine the patient level of consciousness by Glasgow coma scale

*patient is placed in a comfortable position to prevent from falling

*Provided a written and verbal reminders of place ,time and plan of care to the patient to prevent confusion related memory loss

*Determine the levels of ammonia

*Administered medication as per physicians order such as lactulose to manage ammonia acidosis

Evaluation:

The patient is oriented to time,place and date and there is no confusion, and he is alert

*Ecourage the family members to maintain a good communication

*Educate the patient and family members to prevent from falling

*Take the medications according to the time

*Maintain adequate hydration and nutrition

2.Imbalanced nutrition less than body requirements related to insufficient intake of foods

Assessment:

*Assess for the weight loss

*Assess for the changes in the bowel sounds and function

*Assess for the mucle wasting by assessing the muscle tone

*Assess for the dietry pattern

Goals:

*The patient maintains the adequate nutrition level by progressive weight gain and no signs of imbalanced nutrition

Interventions:

*weighed the patient and measure the skin fold and fluid status of the patient

*Measure the dietary intake of the patient

*Encourage the patient to take diiferent types of foods included in the diet according to the likes(consider his/her preferences in food choices)

*Encourage the patient to take the supplementary feedings with the meals

*Give small,frequent meals

*Avoid those food that containing ammonium to avoid further complications

*Restrict the intake of beverages and caffeine

*Encourage to take soft foods

*Monitor lab studies includes protein,albumin and ammonia

*Provide adequate high caloric foods with simple carbohydrates

Evaluation:

Patient having normal bowel pattern and gained a normal muscle tone

Patient Teaching:

*Avoid the patient to take rich carbohydrates

*Educate the patient to avoid smoking and alcoholism

*Encourage to take high caloric diet

*Educate regarding importance of follow up

3.Risk for injury related to disorientation or even unconscious state

Assessment:

*Assess for the risk factors for injury

*Assess for any signs and symptoms of increased ICP such as head ache,vomitting,irritability etc

*Assess for lab investigations for knowing the metabolic acidosis resulting from high ammonia levels

Goals:

The client remains free of injury

Intervention:

*Monitored the level of conscious of patient

*Keep the side rails up and bed be in lowest position

*Use padded side rails toprevent from injury

*Give adequate support to the limbs while moving the patient

Evaluation:

There is no signs of any neurological complications and the patient is not having any injury

Teaching:

*Educate the family members regarding the importance of giving adequate support while moving

*Educate the family members regarding how to assess the alertness of patient

*Educate the family members regarding the importance of putting side rails