ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Fluid volume Cirrhosis of After 8 hours INDEPENDENT: After 8 hours of

“Napansin ko na excess the liver of nursing nursing
lumalaki ang related to is a chronic interventions Measure intake and Reflects circulating interventions,
tiyan ko” compromise disease that , the patient output, weigh daily, volume status. the patient was
(I feel that my d regulatory causes cell will and note weight Positive balance/ able to
tummy is getting mechanism. destruction demonstrate gain more than 0.5 weight gain often demonstrate
bigger) and fibrosis stabilized kg/day. reflects continuing stabilized fluid
as verbalized by (scarring) of fluid volume fluid retention. volume and
the patient. hepatic and decreased
tissue. decreased Assess respiratory Indicative of edema.
OBJECTIVE: Fibrosis alters edema status, noting pulmonary
• normal liver increased congestion.
Anasarca structure and respiratory rate,
• vasculature, dyspnea.
Weight gain impairing Blood pressure
• blood and Monitor blood elevation usually
Altered electrolyte lymph flow pressure. associated with
levels and resulting fluid volume excess
• in hepatic but may not occur
Oliguria insufficiency because of fluid
• and shifts out of the
V/S taken as hypertension vascular space.
follows:T: 37.3P: in the portal
89R: 20BP: vein. Increasing
120/80 Complications Auscultate lungs, pulmonary
include noting diminished/ congestion may
hyponatremia absent breath result in
, water sounds and consolidation,
retention, developing impaired gas
bleeding adventitious sounds. exchange, and
esophageal complications.
varices. Assess degree of
Coagulopathy peripheral/ Fluid shift into
, spontaneous dependent edema. tissues as a result
bacterial of sodium and
peritonitis, water retention,
and hepatic decreased albumin,
and increased anti
encephalopat Measure abdominal diuretic hormone
hy girth. (ADH).
.
Reflects
accumulation of
fluid (ascites)
resulting from loss
Encourage bed rest of plasma proteins
when ascites is or fluid into
present. peritoneal space.

May promote
COLABORATIVE: recumbency-
induced diuresis.
Administer
medications as
indicated. Such as
diuretics. To control edema
and ascites.
Monitor electrolytes.

To correct further
imbalances.