Assessment Nursing Inference Goal Nursing Rationale Evaluation

Diagnosis Intervention
SUBJECTIVE: Excess fluid Cirrhosis of Short term: INDEPENDENT:
volume related to the liver Goal Met
“Nahirapan akong compromised is a chronic After 8 hours Measure intake and Reflects circulating
regulatory disease that of nursing output, weigh daily, volume status. Short term:
huminga lalo na mechanism causes cell interventions
pag ako’y destruction the patient and note weight Positive balance/ After 8 hours
nakahiga” as and fibrosis will gain more than 0.5 weight gain often of nursing
verbalized by the (scarring) of demonstrate kg/day. reflects continuing interventions
client. hepatic fluid retention. the patient
tissue. >decrease was able to
Fibrosis alters fluid volume demonstrate
normal liver Assess respiratory
structure and >decrease >decreased fluid
OBJECTIVE: vasculature, bipedal edema status, noting Indicative of volume
impairing increased pulmonary
>abdominal blood and respiratory rate, congestion. >decreased
enlargement lymph flow bipedal edema
dyspnea.
and resulting
> DOB in hepatic
insufficiency
> Hooked to O2 1 Blood pressure
and Long term: Long term:
L/min via nasal hypertension Monitor blood elevation usually
cannula. in the portal After 2-3 days of pressure associated with After 2-3 days of
vein. nursing fluid volume nursing
>altered Complications interventions the interventions the
electrolytes excess
include client will be able client was able to
but may not occur
hyponatremia to demonstrate demonstrate
K= 2.9 meq/L , water behaviors to because of fluid behaviors to
(09-20-10) shifts out of the
 retention, monitor fluid status monitor fluid status
>Bipedal edema bleeding and reduce vascular space. and reduce
esophageal recurrence of fluid recurrence of fluid
>Crackles and varices. excess as Auscultate lungs, Increasing excess as
wheezes Coagulopathy evidence by: evidenced by:
, spontaneous noting diminished/ pulmonary
>pleural effusion & bacterial peritonitis >maintain to absent breath congestion may >maintained
ascites (CT-scan & and hepatic normal electrolytes sounds and result in normal electrolytes
UTZ of abdomen) encephalopathy developing consolidation,
>absence of adventitious impaired gas >absencedof
>Hgb= 118 bipedal edema bipedal edema
>Hct = 0.343 sounds. exchange, and
complications.
VS:
Fluid shift into
Temp.:36.3 °C Assess degree of tissues as a result
PR: 87 bpm peripheral/ of sodium and
RR: 27 breaths/min
BP: 110/60 mmHg dependent edema water retention,
decreased
albumin,
and increased anti
diuretic hormone
(ADH).

Measure abdominal Reflects

girth. accumulation of
fluid (ascites)
resulting from loss
 of plasma proteins
or fluid into
peritoneal space.
Encourage bed rest
when ascites is May promote
present. recumbency-
COLLABORATIVE induced diuresis.
:

Administer
To control edema
medications as and ascites.
indicated. Such as
diuretics.

Monitor electrolytes To correct further

imbalnces.