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NURSING CARE PLAN ASSESSMENT SUBJECTIVE: DIAGNOSIS INFERENCE PLANNING INTERVENTION INDEPENDENT: Measure intake and output, weigh daily, and note weight gain more than 0.5 kg/day. RATIONALE Reflects circulating volume status. Positive balance/ weight gain often reflects continuing fluid retention. EVALUATION After 8 hours of nursing interventions, the patient was able to demonstrate stabilized fluid volume and decreased edema.

Fluid volume excess related to Napansin ko na compromised lumalaki ang tiyan regulatory ko (I feel that my mechanism.
tummy is getting bigger) as

verbalized by the patient. OBJECTIVE: Anasarca Weight gain Altered electrolyte levels Oliguria V/S taken as follows: T: 37.3 P: 89 R: 20 BP: 120/80

Cirrhosis of the 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.

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

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

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.

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

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Assess degree of peripheral/ dependent edema.

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.

Measure abdominal girth.

Encourage bed rest when ascites is present.

COLABORATIVE: Administer medications as indicated. Such as diuretics. Monitor electrolytes.

To control edema and ascites.

To correct further imbalances.