Assessment Subjective:
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Assessment SUBJECTIVE:
“Napansin ko na lumalaki ang tiyan ko.
OBJECTIVE:
•
Abdominal edema
•
Pruritus noted
•
With intact peritoneal wound dressing
•
Weak and pale in appearance
•
V/S taken as follows:
Explanation of the Problem Cirrhosis of
Objectives
After 8 hours of nursing interventions, the the patient liver is a will chronic disease demonstrate that causes stabilized cell fluid volume destruction and and decreased fibrosis edema. (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,
Intervention INDEPENDENT: •
•
Rationale •
Reflects circulating volume status. Positive balance/ weight gain often reflects continuing fluid retention.
•
Indicative of pulmonary congestion.
Measure intake and output, weigh daily, and note weight gain more than 0.5 kg/day.
Assess respiratory status, noting increased respiratory rate,
Evaluation After 8 hours of nursing interventions, the patient was able to demonstrate stabilized fluid volume and decreased edema.
T: 37.3 P: 105 R: 22 BP: 110/70
Nursing Diagnosis:
Fluid volume excess related to compromised regulatory
bleeding esophageal varices. Coagulopathy, spontaneous bacterial peritonitis, and hepatic encephalopathy.
dyspnea.
•
Monitor blood pressure.
•
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 consolidatio n, impaired gas exchange, and
mechanism
•
•
Auscultate lungs, noting diminished/ absent breath sounds and developing adventitious sounds.
complication s.
•
Measure abdominal girth.
Reflects accumulation of fluid (ascites) resulting from loss of plasma proteins or fluid into peritoneal space.
• •
May promote recumbencyinduced diuresis.
•
• •
Encourage bed rest when ascites is present.
Administer medications as indicated. Such as diuretics.
.
To control edema and ascites.
“Napansin ko na lumalaki ang tiyan ko.
OBJECTIVE:
•
Abdominal edema
•
Pruritus noted
•
With intact peritoneal wound dressing
•
Weak and pale in appearance
•
V/S taken as follows:
Explanation of the Problem Cirrhosis of
Objectives
After 8 hours of nursing interventions, the the patient liver is a will chronic disease demonstrate that causes stabilized cell fluid volume destruction and and decreased fibrosis edema. (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,
Intervention INDEPENDENT: •
•
Rationale •
Reflects circulating volume status. Positive balance/ weight gain often reflects continuing fluid retention.
•
Indicative of pulmonary congestion.
Measure intake and output, weigh daily, and note weight gain more than 0.5 kg/day.
Assess respiratory status, noting increased respiratory rate,
Evaluation After 8 hours of nursing interventions, the patient was able to demonstrate stabilized fluid volume and decreased edema.
T: 37.3 P: 105 R: 22 BP: 110/70
Nursing Diagnosis:
Fluid volume excess related to compromised regulatory
bleeding esophageal varices. Coagulopathy, spontaneous bacterial peritonitis, and hepatic encephalopathy.
dyspnea.
•
Monitor blood pressure.
•
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 consolidatio n, impaired gas exchange, and
mechanism
•
•
Auscultate lungs, noting diminished/ absent breath sounds and developing adventitious sounds.
complication s.
•
Measure abdominal girth.
Reflects accumulation of fluid (ascites) resulting from loss of plasma proteins or fluid into peritoneal space.
• •
May promote recumbencyinduced diuresis.
•
• •
Encourage bed rest when ascites is present.
Administer medications as indicated. Such as diuretics.
.
To control edema and ascites.
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