Assessment Explanation of Objectives Intervention Rationale Evaluation

the Problem

SUBJECTIVE: Cirrhosis of After 8 hours INDEPENDENT: • Reflects After 8 hours

of nursing circulating of nursing
interventions, • Measure volume interventions,
the intake and
the patient status. the patient
“Napansin ko liver is a output,
will Positive was able to
na lumalaki chronic disease weigh daily,
demonstrate balance/ demonstrate
ang tiyan ko. that causes and note
stabilized weight gain stabilized
cell weight gain
fluid volume often fluid volume
destruction and more than
and decreased reflects and decreased
OBJECTIVE: fibrosis 0.5 kg/day.
edema. continuing edema.
(scarring) of
fluid
hepatic tissue.
retention.
Fibrosis alters
• Abdominal normal liver
edema structure and
vasculature,
• Pruritus
impairing blood
noted
and lymph flow
• With intact and resulting
peritoneal in hepatic
wound insufficiency • Indicative
dressing and of pulmonary
hypertension in congestion.
• Weak and the portal • Assess
pale in vein. respiratory
appearance Complications status,
include noting
• V/S taken as increased
hyponatremia,
follows: respiratory
water
retention, rate,
 bleeding dyspnea.
esophageal
T: 37.3 varices.
Coagulopathy,
P: 105
spontaneous
R: 22 bacterial • Monitor • Blood
peritonitis, blood pressure
BP: 110/70 and hepatic pressure. elevation
encephalopathy. usually
associated
with fluid
volume
excess but
may not
occur
because of
fluid shifts
out of the
vascular
space.

• Increasing
Nursing pulmonary
Diagnosis: congestion
may result
in
consolidatio
Fluid volume n, impaired
excess related gas
to compromised exchange,
regulatory and
mechanism • Auscultate complication
lungs, s.
noting
diminished/
absent
breath
sounds and
developing
adventitious
sounds.
• Reflects
accumulation
of fluid
(ascites)
resulting
from loss of
plasma
proteins or
fluid into
peritoneal
• Measure space.
abdominal
girth.

• May promote
recumbency-
induced
diuresis.
 • To control
edema and
ascites.

• Encourage
bed rest
when ascites
is present.

Administer
medications
as
indicated.
Such as
diuretics.