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NursingCrib.

com – Student Nurses’ Community


NURSING CARE PLAN
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
INDEPENDENT:
SUBJECTIVE: Fluid volume • After 8 hours of • Measure intake • Reflects circulating  After 8 hours of
excess related to Cirrhosis of the nursing and output, volume status. nursing
“Napansin ko na compromised liver is a chronic interventions, weigh daily, and Positive balance/ interventions, the
lumalaki ang tiyan regulatory disease that the patient will note weight gain weight gain often patient was able
ko” (I feel that my mechanism. causes cell demonstrate more than 0.5 reflects continuing to demonstrate
tummy is getting destruction and stabilized fluid kg/day. fluid retention. stabilized fluid
bigger) as fibrosis (scarring) volume and volume and
verbalized by the of hepatic tissue. decreased decreased
patient. Fibrosis alters edema. edema.
normal liver
OBJECTIVE: structure and • Assess • Indicative of
vasculature, respiratory pulmonary
• Anasarca impairing blood status, noting congestion.
• Weight gain and lymph flow increased
• Altered and resulting in respiratory rate,
electrolyte hepatic dyspnea.
levels insufficiency and
• Oliguria hypertension in • Monitor blood • Blood pressure
• V/S taken as the portal vein. pressure. elevation usually
follows: Complications associated with
include fluid volume
T: 37.3 hyponatremia, excess but may
P: 89 water retention, not occur because
R: 20 bleeding of fluid shifts out of
BP: 120/80 esophageal the vascular
varices. space.
Coagulopathy,
spontaneous • Auscultate • Increasing
bacterial lungs, noting pulmonary
peritonitis, and diminished/ congestion may
hepatic absent breath result in
encephalopathy. sounds and consolidation,
developing impaired gas
adventitious exchange, and
sounds. complications.
NursingCrib.com – Student Nurses’ Community

• Assess degree • Fluid shift into


of peripheral/ tissues as a result
dependent of sodium and
edema. water retention,
decreased
albumin, and
increased anti
diuretic hormone
(ADH).

• Measure • Reflects
abdominal girth. accumulation of
fluid (ascites)
resulting from loss
of plasma proteins
or fluid into
peritoneal space.

• Encourage bed • May promote


rest when recumbency-
ascites is induced diuresis.
present.

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

• Monitor • To correct further


electrolytes. imbalances.