NURSING CARE PLAN ASSESSMENT Subjective: Lumalaki ang tiyan ko at minsan sumasakit din as verbalized by the patient.

Objective: - Enlarged/ distended abdomen - (+) weight gain - limited movement - weak and pale in appearance -(+)tenderness during palpation DIAGNOSIS Fluid volume excess related to compromised regulatory mechanism. INFERENCE Cirrhosis GOAL INTERVENTON Measure intake and output, weigh daily, and note weight gain more than 0.5 kg/day. Assess respiratory status, noting increased respiratory rate, dyspnea. Monitor blood pressure. RATIONALE Reflects circulating volume status. Positive balance/ weight gain often reflects continuing fluid retention. Indicative of pulmonary congestion. EVALUATION After 8 hours of nursing interventions, the patient demonstrated stabilized fluid volume, decreased edema, decreased abdominbal girth, increased urine output,and a good rest and sleep

After 8 hours of nursing portal hypertension interventions, the patient will sphlenic arterial demonstrate vasodilation stabilized fluid volume and decrease in effective decreased edema. arterial volume decrease in renal blood flow water and sodium retention renal vasoconstriction ascites formation

Blood pressure elevation usually associated with fluid volume excess but may not occur because of fluid shifts out of the vascular space. Fluid shift into tissues as a result of sodium and water retention, decreased albumin, and increased anti diuretic hormone (ADH).

Assess degree of peripheral/ dependent edema.

Measure abdominal Reflects girth. accumulation of fluid (ascites) resulting from loss of plasma proteins or fluid into peritoneal space. Encourage bed rest when ascites is present. Administer medications as indicated. Such as diuretics. Monitor electrolytes. May promote recumbencyinduced diuresis. To control edema and ascites

To correct further imbalances.

NURSING CARE PLAN ASSESSMENT Subjective: Nanlalata at nanghihina ako as verbalized by the patient Objective: Vital Signs: BP: 100/40 PR:97 bpm RR:24 cpm Temp: 37.1 C - Pale looking - Body malaise - Limited movement - fatigue DIAGNOSIS Anemia related to activity intolerance INFERENCE Cirrhosis GOAL INTERVENTON RATIONALE EVALUATION After 8 hours of nursing interventions, the patient are able to verbalize feeling comfort and relief, Able to move freely, improvement in skin color

After 8 hours of nursing portal hypertension interventions, the patient will be able sphlenic arterial to verbalize feeling vasodilation of comfort and relief. decrease in effective arterial volume decrease in renal blood flow water and sodium retention renal vasoconstriction ascites formation

Note presence of Fatigue affects both factors contributing the client's actual to fatigue and perceived ability to participate in activities Perceived limitations, and severity of deficit in light of usual status Provides comparative baseline and information about needed education or interventions regarding quality of life Symptoms may be result of contribute to intolerance of activity

Note client reports of weakness, fatigue , pain, difficultyaccomplish ing task, and/or insomia Ascertain ability to stand and move about, and degree of assistyance necessary or use of equipment Identify activity needs versus desires to evaluate

To determine current status and needs associated with participation in needed

appropriateness Provide positive atmosphere, while acknowledging difficulty of the situation for the client Helps to minimize frustration and rechannel energy

Provide comfort To enhance ability measures and to participate in provide for relief of activities pain