Global City Innovative College

College of Nursing and International Health Studies

NURSING CARE PLAN
Padilla, Madon Angelica S. Bautista,
Raymund, RN.
Mandaluyong City Medical Center
January 23, 2010
 Assessment Diagnosis Scientific Planning Intervention Rationale Evaluation
Rationale
Subjective: Fluid excess Drinking Short term: Independent:
N/A volume Alcohol In the course -Measure -reflects At the end of
Patient cannot related to of the intake and circulating the 8-hour
really compromised Absorbs intervention output. Weigh volume status. shift the client
verbalize regulatory alcohol in your the client will daily and note Weight gain is has gained
feelings due to mechanism as blood. Blood is understand weight gain. a sign of knowledge
weakness. manifested by processed in the cause of continuous about his
enlarged the liver . the fluid retention. condition.
Objective: stomach. enlargement -assess vital -respiratory is
-Abdominal The liver turns of his signs very important At the end of
area is bigger alcohol to stomach. regularly. because there the 8-hour
than the usual water and might be shift the client
body size carbon In 2 hours the pulmonary will decrease
requirement. dioxide. patient will congestion. his pressure in
-Eyes are feel less the abdomen
yellow (Liver can only pressure in the -fluid excess and decrease
metabolize area with -monitor blood maybe fluid volume.
certain increased fluid pressure associated
amounts of volume and with high
alcohol) decreased blood
drinking more edema. pressure.
alcohol -measure size
Long term: of abdominal -this will help
Increases In 2-3 weeks area. Note if you monitor
alcohol level in the patient will its getting the patient
blood stream. learn how to larger or decreased
live healthy decreasing in abdominal
Loss of and stay away size. area may be a
albumin from alcoholic good sign.
beverages.
-Bedrest -may promote
Portal recumbency-
hypertension induced
increase dieresis.
hepatic Independent:
pressure or -Monitor
liver blood electrolytes -to correct
flow further
-Administer imbalances
Accumulation medications
of fluids in the
peritoneum Vitamin K

Causing -prevention of
symptoms Ceftriaxone hemorrhage