Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective: “I feel  Fluid volume  After 6 hours of  Monitor vital  Established  After 6 hours of
tenderness in my excess r/t nursing sign baseline data nsg.
right upper compromised interventions,  Reflects circulating interventions,
quadrant of regulatory patient will  Measure intake volume status, the patient
stomach” mechanism demonstrate and output developing fluid demonstrated
complained by the stabilized fluid shifts, and in stabilized fluid
patient. volume and response to volume and
decreased and therapy decreased
Objective: tenderness in  Monitor blood  Blood pressure tenderness in
 Malaise abdomen pressure elevations are abdomen
 Low grade usually associated
fever with fluid volume Goal met.
 Dark urine excess
 Jaundice  Assess  Indicative of
 Tenderness respiratory pulmonary
on abdomen status congestion/edema
noted  Reflects
 Pain in joints  Monitor accumulation of
abdominal fluid (ascites)
girth  Decreases
 Provide sensation of thirst,
occasional ice especially when
chips if NPO fluid intake is
restricted
 Sodium may be
 Restrict sodium restricted to
and fluids as minimize fluid
ordered retention in
extravascular
spaces. Fluid
restriction may be
necessary to
prevent dilutional
hyponatremia
  Administer
medications as
indicated:
 Diuretics  Used with caution
to control edema
and ascites, block
effect of
aldosterone, and
increase water
excretion while
 Potassium sparing potassium
 Serum and cellular
potassium are
usually depleted
 Assist with because of liver
paracentesis disease
procedure  Done to remove
ascites fluid

REFLECTION:
Liver is one of the most important organs in the human body. It holds so many function and supports other organ system. I have learn
that liver cirrhosis is a slowly progressing disease which scar tissue and replaces healthy tissues. And once the tissue scars it interrupts
normal function of the liver and the blood flow through liver where the function of the liver can no longer take place. And the causes
of cirrhosis maybe alcohol abuse, fatty liver and hepatitis C. Clinical manifestation includes fatigue or exhaustion, loss of appetite,
yellowing of the skin or eyeballs, weight loss/ weight gain, and edema of legs and ankle. Food is a great foundation of the good
treatment plan and healthy lifestyle as well.
 Page 1

Date: April, 22 2021

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Liver is one of the most important organs in the human body. It holds so many function and
supports other organ system. I have learn that liver cirrhosis is a slowly progressing disease
which scar tissue and replaces healthy tissues. And once the tissue scars it interrupts normal
function of the liver and the blood flow through liver where the function of the liver can no
longer take place. And the causes of cirrhosis maybe alcohol abuse, fatty liver and hepatitis C.
Clinical manifestation includes fatigue or exhaustion, loss of appetite, yellowing of the skin or
eyeballs, weight loss/ weight gain, and edema of legs and ankle. Food is a great foundation of
the good treatment plan and healthy lifestyle as well.

Source
20% Plagiarized

Common Liver Diseases | Liver Disease Treatment in Texas

https://www.theliverinstitutetx.com/about-us/liver-liver-disease/#:~:text=Did%20you%20know%20that%20the,relating%20to%20how%20and%20why.