Nursing Care Plan

Assessment
Subjective: Napansin
ko na lumalaki ang
tiyan ko as verbalized
Objective:
Pallor
Weak in
appearance
Jaundice
Abdominal
distention noted
Bipedal edema
Irritability noted
DOB with RR of 29
bpm
Abdominal girth of
32

Diagnosis

Fluid volume
excess r/t
compromised
regulatory
mechanism
secondary to
cirrhosis of the
liver as manifested
by pallor, weak in
appearance,
jaundice,
abdominal
distention, edema,
irritability, DOB
with RR of 29 and
abdominal girth of
32

Planning

After 6 hours of
nursing
interventions,
patient will
demonstrate
stabilized fluid
volume and
decreased edema
and abdominal
girth.

Interventions

Rationale

Monitor vital sign

Measure intake
and output

Monitor BP

Assess respiratory
status
Monitor abdominal
girth
Provide occasional
ice chips if NPO

Restrict sodium
and fluids as
ordered

Established
baseline data
Reflects circulating
volume status,
developing fluid
shifts, and in
response to
therapy
BP elevations are
usually associated
with fluid volume
excess
Indicative of
pulmonary
congestion/edema
Reflects
accumulation of
fluid (ascites)
Decreases
sensation of thirst,
especially when
fluid intake is
restricted
Sodium may be
restricted to
minimize fluid
retention in
extravascular
spaces. Fluid

Evaluation

After 6 hours of
nsg. interventions,
the patient
demonstrated
stabilized fluid
volume and
decreased edema
and abdominal
girth.
Goal met.

restriction may be
necessary to
prevent dilutional
hyponatremia

Administer
medications as
indicated:
Diuretics

Potassium

Assist with
paracentesis
procedure

Used with caution

to control edema
and ascites, block
effect of
aldosterone, and
increase water
excretion while
sparing potassium
Serum and cellular
potassium are
usually depleted
because of liver
disease
Done to remove
ascites fluid

Nursing Care Plan

Assessment
Subjective: Wala akong
ganang kumain as
verbalized
Objective:
Weak in
appearance
Refusal to eat
Irritability noted
Poor muscle tone
Jaundice noted
Emaciated
Abdominal
distention noted
Pallor noted

Diagnosis

Imbalance
nutrition: less than
body requirements
r/t loss of appetite
secondary to
ascites as
evidenced by
refusal to eat,
weak in
appearance,
irritability, poor
muscle tone,
emaciated and
abdominal
distention

Planning

After 5 hrs of nsg.

Interventions,
patients appetite
will improve from 2
tbsp to at least 5
tbsp per meal.

Interventions

Rationale

Monitor vital signs

For baseline data

Assist in oral
hygiene before
meals.
Discuss eating
habits including
food preferences.
Serve favorite
foods that are not
contraindicated.
Prevent or
minimize
unpleasant odors
during meal time.
Serve foods that
are attractive and
palatable.
Recommend small,
frequent meals

A clean mouth
enhances appetite
To appeal to client
likes and dislikes

To stimulate the
appetite

May have negative

effect on appetite

To stimulate the
appetite

Poor tolerance to
larger meals may
be due to
increased intraabdominal
pressure/ascites
Aids in reducing
gastric irritation &
abdominal
discomfort that
may impair oral
intake/digestion

Restrict intake of
caffeine, gasproducing or spicy
and excessively
hot or cold foods

Evaluation

After 8 hours of
nursing
interventions,
patients appetite
improved from 2
tbsp to 5 tbsp per
meal.
Goal met.

Provide assistance
with activities as
needed. Promote
undisturbed rest
periods, especially
before meals
Advise to consume
nutritious foods

Conserving energy
reduces metabolic
demands on the
liver and promotes
cellular
regeneration.

Nursing Care Plan

Assessment
Subjective:
Sumasakit ang tiyan
ko as verbalized with a
pain scale of 6 out of 10
where in:
0 - no pain
1 2 mild pain
3 4 moderate pain
5 6 severe pain
7 8 very severe pain
9 10 worst possible
Objective:
Facial grimace
noted
Irritability noted
Restlessness noted
Anxiety noted
Fatigued
Clenched fist
Beaten look
Agitation noted
Pallor
Grunting
Guarding of body
part (right
hypochondriac)

Diagnosis

Acute pain related

to liver
enlargement
secondary to
ascites as
evidenced by facial
grimace,
irritability,
restlessness,
anxiety, fatigued,
clenched fist,
beaten look,
agitation, pallor,
grunting, guarding
of body part and
verbalization of
pain with a pain
scale of 6/10

Planning

After 2 hours of
nursing
interventions,
pain will be
lessened with a
scale of 1-10,
from 6/10 to
1/10.

Interventions

Monitor VS
Perform pain
assessment
(COLDSPA) every
time pain occurs

Rationale

Encourage
verbalization of
feeling of pain

Instruct use of
relaxation exercise
such as listening to
music
Provide comfort
measures such as
back rubbing &
changing position
Teach the patient
relaxation
techniques like deep
breathing
Provide quiet and
calm environment

Pain alters VS
To rule out
development of
complications by
knowing alleviating
and precipitating
factors
Pain is subjective &
cant be assessed
through
observation alone
Promotes
relaxation and
diverts attention
from pain
To prove nonpharmacological
management

To alleviate pain

Noisy environment
stimulates
irritation

Evaluation

After 2 hours of
nursing
interventions,
patient was
relieved from pain
Goal met.

Nursing Care Plan

Assessment
Subjective:
Nahihirapan
akong huminga as
verbalized
Objective:
Dyspnea
Tachypnea with RR
of 30, irregular,
shallow
Weak in
appearance
Anxiety noted
Irritability noted
Restlessness noted
Lethargic
Pallor

Diagnosis

Altered breathing
pattern r/t
decreased lung
expansion
secondary to intraabdominal fluid
collection (ascites)
as manifested by
dyspnea,
tachypnea with RR
of 30, irregular and
shallow, weak in
appearance,
anxiety, irritability,
restlessness,
lethargy and pallor

Planning

After 6 hours of
nursing
interventions,
patient will be
relieved from
dyspnea and
breathing pattern
will return to
normal.

Interventions

Monitor V/S
Monitor respiratory
rate, rhythm and
depth

Auscultate breath
sounds, noting
crackles, wheezes
and rhonchi
Investigate
changes in LOC

Rationale

Keep head of bed

elevated. Position
on sides
Encourage
frequent
repositioning and
deep-breathing
exercises
Provide
supplemental O2
as indicated

For baseline data

Rapid shallow
respirations/dyspn
ea may be present
because of hypoxia
or fluid
accumulation in
the abdomen
Indicates
developing
complications and
increasing risk of
infection
Changes in
mentation may
reflect hypoxemia
and respiratory
failure
Facilitates
breathing by
reducing pressure
on the diaphragm
Aids in lung
expansion and
mobilizing
secretions
May be necessary
to treat/prevent

Evaluation

After 6 hours of
nsg. interventions,
patient was
relieved from
dyspnea and
breathing pattern
returned to normal
Goal met.

hypoxia

Nursing Care Plan

Assessment

Diagnosis

Planning

Interventions

Rationale

Evaluation

Subjective:
Nanghihina na
ako, ayoko na
mag-gagalaw as
verbalized
Objective:
Pallor
Body malaise
noted
Diaphoresis
Inability to
concentrate
Inability to perform
usual ADLs
Weak in
appearance
Limited ROM
Difficulty initiating
movements

Activity intolerance
r/t generalized
body weakness
secondary to
progressive
disease state as
manifested by
pallor, body
malaise,
diaphoresis,
inability to
concentrate,
inability to perform
usual ADLs, weak
in appearance,
limited ROM and
difficulty initiating
movements

After 8 hours of
nursing
interventions,
patient will
participate
willingly in
necessary activity,
will learn how to
conserve energy
and verbalize relief
from fatigue.

Evaluate pts
current activity
tolerance
Adjust activity and
reduce intensity of
task that may
cause undesired
physiological
changes
Increase exercise
and activity levels
gradually
Teach methods to
conserve energy
such as sitting
than standing
while dressing
Demonstrate/Assis
t the patient while
doing ADL
Give the patient
information that
provides evidence
progress
Encourage client to
do whatever
possible e.g. selfcare

Provide
cooperative
baseline
To prevent over
exertion

Enhances activity
tolerance

Helps minimize
waste of energy

Protect patient
from injury

To sustain pts
motivation

Provides for sense

of control and
feeling of
accomplishment

After 8 hours of
nursing
interventions,
patient
participated
willingly in
necessary
activities, learned
how to conserve
energy and
verbalized relief
from fatigue
Goal met

Nursing Care Plan

Assessment
Subjective:
Mawawala ba pa
tong laki ng tiyan
ko? as verbalized
Objective:
Anxiety noted
Fear of rejection
Irritability noted
Restlessness noted
Feeling of
helplessness
Negative feelings
about body

Diagnosis

Disturbed body
image r/t altered
physical
appearance as
evidenced by
anxiety, fear,
irritability,
restlessness,
feeling of
helplessness and
negative feelings
about the body

Planning

After 8 hours of
nursing
interventions,
patient will
verbalize
understanding of
changes and
acceptance of self
in the present
situation.

Interventions

Discuss
situation/encourag
e verbalization of
fears and
concerns. Explain
relationship
between nature of
disease
and symptoms.

Support and
encourage patient;
provide care with a
positive, friendly
attitude

Encourage family
to verbalize
feelings, visit
freely/participate
in care

Rationale

Patient is very
sensitive to body
changes and may
also experience
feelings of guilt
when cause is
related to
alcohol (70%) or
other drug use.
Caregivers
sometimes allow
judgmental
feelings to affect
the care of patient
and need to make
every effort to help
patient feel valued
as a person.
Family members
may feel guilty
about patients
condition
and may be fearful
of impending death.
They need
nonjudgmental
emotional support
and free access to
patient.
Participation in care

Evaluation

After 8 hours of
nursing
interventions,
patient verbalized
understanding of
changes and
acceptance of self
in the present
situation.
Goal met

helps them feel

useful and
promotes trust
between staff,
patient.

Nursing Care Plan

Assessment

Diagnosis

Planning

Interventions

Rationale

Evaluation

Subjective:
Lagi akong
nangangati at
parang mahapdi
balat ko as
claimed
Objective:
Pruritus noted
Dry skin
Erythema noted
Scaly skin

Risk for impaired

skin integrity r/t
altered circulation
secondary to
accumulation of
bile salts as
evidenced by
pruritus, erythema,
dry and scaly skin

After 7 hours of
nursing
interventions,
patient will
maintain skin
integrity and
identify individual
risk factors and
demonstrate
behaviors/techniqu
e to prevent skin
breakdown.

Inspect skin
surface/pressure
points routinely.
Gently massage
bony prominences
or areas of
continued stress

Encourage/assist
with repositioning
on a regular
schedule while in
bed, chair and
active passive
ROM exercises as
appropriate

Keep linen dry and

free of wrinkles

Suggest clipping
finger nails short

Edematous tissues
are more prone to
breakdown and to
the formation of
decubitus ulcers.
Ascites may
stretch the skin to
the point of tearing
in severe cirrhosis
Repositioning
reduces pressure
on edematous
tissues to improve
circulation.
Exercises enhance
circulation and
improve, maintain,
joint mobility
Moisture
aggravates
pruritus and
increases risk of
skin breakdown
Prevents client from
inadvertently
injuring the skin
especially while
sleeping

After 3 hours of
nursing
interventions,
patient maintained
skin integrity and
identified
individual risk
factors and
demonstrated
behaviors/techniqu
es to prevent skin
breakdown.
Goal met

Nursing Care Plan

Assessment
Subjective:
Nahiirapan akong
umihi as
verbalized
Objective:
Anxiety noted
Irritability noted
Restlessness noted
Small, frequent
voiding
Facial grimace
noted upon
urination
Excessive
diaphoresis when
trying to void
Urgency

Diagnosis

Impaired urinary
elimination r/t
bladder distention
secondary to
ascites as
evidenced by
anxiety, irritability,
restlessness, small
and frequent
voiding, facial
grimace upon
urination,
excessive
diaphoresis when
trying to void, and
urgency

Planning

After 8 hours of
nursing
interventions,
patient will empty
bladder regularly
with decrease pain
and difficulty.

Interventions

Rationale

Palpate bladder.
Investigate reports
of discomfort,
fullness, inability to
void

Provide routine
voiding measures
like privacy,
normal positioning,
running water in
sink, pouring warm
water over
abdomen

Perception of
bladder fullness,
distention of
bladder above
symphysis pubis
indicates urinary
retention
Promotes
relaxation urinary
muscles and may
facilitate voiding
efforts

Evaluation

After 8 hours of
nursing
interventions,
patient voided
regularly and
without difficulty.
Goal met

Nursing Care Plan

Assessment
Subjective:
Anu kaya tong
sakit ko, san ko
nakuha to? as
verbalized
Objective:
Restlessness noted
Irritability noted
Confused look
Statement of
misconception
Development of
preventable
complications
Frequent questions

Diagnosis

Knowledge deficit
regarding
condition,
prognosis,
treatment and
discharge needs r/t
information
misinterpretation
as evidenced by
restlessness,
irritability,
confused look,
statement of
misconception,
development of
preventable
complications and
frequent questions

Planning

After 8 hours of
nursing
interventions,
patient will
verbalize
understanding of
disease process,
prognosis,
potential
complications and
identify necessary
lifestyle changes
and participate in
care.

Interventions

Review disease
process/prognosis
and future
expectations
Stress importance
of avoiding alcohol.
Give information
about community
services available
to aid in alcohol
rehabilitation if
indicated.
Emphasize the
importance of
good nutrition.
Recommendavoida
nce of highprotein/salty foods,
onions, and
strongcheeses.
Provide written
dietary instructions

Rationale

Provides
knowledge base
from which patient
can make informed
choices
Alcohol is the
leading cause in
the development
of cirrhosis

Proper dietary
maintenance and
avoidance of foods
highin sodium and
protein aid in
remission of
symptoms andhelp
prevent ammonia
buildup and further
liver
damage.Written
instructions are
helpful for patient
to refer to at home

Evaluation

After 8 hours of
nursing
interventions,
patient verbalized
understanding of
disease process,
prognosis,
potential
complications and
identified
necessary lifestyle
changes and
participate in care.
Goal met

Nursing Care Plan

Assessment
Subjective:
Hirap ako
makatulog as
claimed
Objective:
Sunken eyeballs
Fatigue
Mood alterations
Agitated
Body weakness
noted
Lethargic

Diagnosis

Disturbed sleep
pattern r/t changes
in activity pattern
secondary to
psychologic stress
as evidenced by
sunken eyeballs,
fatigue, mood
alterations,
agitation, body
weakness, lethargy

Planning

After 4 hours of
nursing
interventions,
patient will
establish adequate
sleep pattern and
report rested.

Interventions

Evaluate level of
stress

Rationale

Advise to reduce
fluid intake at
night

Increasing
confusion,
disorientation, and
uncooperative
behavior may
interfere with
attaining restful
sleep

Provide soft music

or white noise if
available

Decreases need to
get up to go to
bathroom during
sleep
Reduces sensory
stimulation by
blocking out other
environmental
sounds that could
interfere with restful
sleep

Evaluation

After 4 hours of
nursing
interventions,
patient established
adequate sleep
pattern and
reported rested.
Goal met