ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
SUBJECTIVE: Fluid volume SHORT TERM: INDEPENDENT: INDEPENDENT: SHORT TERM:
 Abdominal pain excess related After 4 hours of After 4 hours of
 Constipation to ascites and nursing  Complete vital  This will assess nursing
edema interventions, signs if there are interventions,
OBJECTIVE: formation as patient will and respiratory pulmonary goal partially
 Bilateral edema evidenced by demonstrate assessment congestions if met, patient
was present on leg swelling. stabilized fluid there is a drop demonstrated
both legs (+3) volume and in RR. An stabilized fluid
 severe ascites decreased increase in BP volume and
 notable edema and can be decreased
absence of abdominal associated with edema and
peripheral girth. fluid retention. abdominal
pulses – Note impaired gas girth.
dorsalis pedis LONG TERM : exchange and
and posterior Within 3 days compromised LONG TERM:
tibial. of giving respiratory Within 3 days
 Bowel sounds nursing function. Assess for of giving
were present in interventions, decreased or labored nursing
all 4 quadrants. the patient will breathing. interventions,
be able to goal partially
 (+) dull
perceive the  Measure intake  Reflects met, the patient
 tender to
reason for fluid and output circulating was able to
palpation
restriction and volume status, perceive the
 irritable will be able to developing fluid reason for fluid
 facial grimace follow orders restriction and
shifts, and in
 Vital Signs appropriately. response to able to follow
BP: 110/64 mm/Hg therapy orders
Temp: 97.7°F appropriately.
 Weight patient  To assess
daily adequacy of
Weight: 201 lb(91 kg)
diet and
measure the
91 kg .
BMI: use of diuretic
5 72 (1.70 m )
'
therapy if
utilized.
= 31.48 Obese  Measure  This will allow a
abdominal girth comparison to
for baseline observe if there
point if is an increase
reference. or decrease in
ascites. This
measure the
effectiveness of
medical
treatments.

 Assess level of  Edema allows

edema from 1- health care
4 and provider to
documents assess if there
finding is an excess 0n
sodium intake
or low serum
albumin.
Ascites is
associated with
low albumin
levels.

 Assist with  If ascites

paracentesis progresses, it
as necessary may be
necessary to
perform
paracentesis to
drain the
abdominal
fluid. Assist
with set-up and
positioning of
patient, post-
 procedure site
assessments,
and monitoring.

 Promote rest to  Impaired liver

conserve function can
energy cause the
patient to be
easily fatigued.
Encourage rest
periods and
cluster care to
conserve
energy for
nutrition and
self-care.

 Restrict sodium  Sodium may be

and fluids as restricted to
ordered minimize fluid
retention in
extravascular
spaces. Fluid
restriction may
be necessary
to prevent
dilutional
hyponatremia

DEPENDENT: DEPENDENT:
 Administer  Diuretics- are
medications as often given to
indicated: manage the
 Diuretics accumulation
  Lactulose of fluid and
 Analgesics edema
 Potassium  Lactulose- a
man-made
sugar that is
given to help
reduce the
amount of
ammonia in the
blood and
prevent hepatic
encephalopath
y
 Analgesics- gi
ven to manage
pain; avoid
acetaminophen
 Potassium-
Serum and
COLLABORATIVE: cellular
 Provide potassium are
adequate usually
nutrition and depleted
education, because of
encourage liver disease
lifestyle and urinary
changes losses.

COLLABORATIVE
 Malnutrition is
often a
complication
of liver
disease but
may go
unnoticed due
to an increase
in weight.
Encourage
and educate
patients to
maintain a
diet low in
sodium and
fat. Avoid
alcohol, seek
treatment for
alcohol
dependence.