NursingCrib.com NURSING CARE PLAN - Liver Cirrhosis

NursingCrib.com – Student Nurses’ Community NURSING CARE PLAN ASSESSMENT SUBJECTIVE: “Napansin ko na lumalaki ang tiyan ko” (I feel that my  tummy is getting  bigger) as

verbalized by the patient. OBJECTIVE: • • •

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Anasarca Weight gain Altered electrolyte levels Oliguria V/S taken as follows: T: 37.3 P: 89 R: 20 BP: 120/80

DIAGNOSIS Fluid volume excess related to compromised regulatory mechanism.

INFERENCE

PLANNING •

Cirrhosis of the liver is liver is a chronic disease that causes cell destruction and fibrosis (scarring) of hepatic tissue. Fibrosis alters normal liver  structure and vasculature, impairing blood and lymph flow and resulting in hepatic insufficiency and hypertension in the portal vein. Complications include hyponatremia, water retention, bleeding esophageal varices. Coagulopathy, spontaneous bacterial peritonitis, and hepatic encephalopathy.. encephalopathy

After 8 hours of  nursing interventions, the patient will demonstrate stabilized fluid volume and decreased edema.

INTERVENTION INDEPENDENT: Measure intake and output, weigh daily, and note weight gain more than 0.5 kg/day. •

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Assess respiratory status, noting increased respiratory rate, dyspnea. Monitor blood pressure.

Auscultate lungs, noting diminished/ absent breath sounds and developing adventitious sounds.

RATIONALE •

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Reflects circulating volume status. Positive balance/ weight gain often reflects continuing fluid retention.

Indicative of  pulmonary congestion.

Blood pressure elevation usually associated with fluid volume excess but may not occur because of fluid shifts out of  the vascular  space. Increasing pulmonary congestion may result in consolidation, impaired gas exchange, and complications.

EVALUATION 

After 8 hours of  nursing interventions, the patient was able to demonstrate stabilized fluid volume and decreased edema.

NursingCrib.com – Student Nurses’ Community

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Assess degree of peripheral/ dependent edema.

Measure abdominal girth.

Encourage bed rest when ascites is present.

COLABORATIVE: Administer  medications as indicated. Such as diuretics. •

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Monitor  electrolytes.

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Fluid shift into tissues as a result of sodium and water retention, decreased albumin, and increased anti diuretic hormone (ADH). Reflects accumulation of  fluid (ascites) resulting from loss of plasma proteins or fluid into peritoneal space.

May promote recumbencyinduced diuresis.

To control edema and ascites.

To correct further  imbalances.