Ncp Liver Cirrhosis

ASSESSMENT SUBJECTIVE: “Napansin ko na lumalaki ang tiyan ko” (I feel that my tummy is getting bigger) as verbalized by the patient. OBJECTIVE: • Anasarca • Weight gain • Altered electrolyte levels • Oliguria • V/S taken as follows:T: 37.3P: 89R: 20BP: 120/80

DIAGNOSIS Fluid volume excess related to compromise d regulatory mechanism.

INFERENCE 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

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

INTERVENTION INDEPENDENT:

RATIONALE

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

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

Assess respiratory status, noting increased respiratory rate, dyspnea.

Indicative of pulmonary congestion.

Monitor blood pressure.

Auscultate lungs, noting diminished/ absent breath sounds and developing adventitious sounds. Assess degree of peripheral/ dependent edema.

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. Fluid shift into tissues as a result of sodium and

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

peritonitis, and hepatic encephalopat hy .

Measure abdominal girth.

water retention, decreased albumin, and increased anti diuretic hormone (ADH).

Encourage bed rest when ascites is present.

Reflects accumulation of fluid (ascites) resulting from loss of plasma proteins or fluid into peritoneal space.

COLABORATIVE: Administer medications as indicated. Such as diuretics.

May promote recumbencyinduced diuresis.

To control edema and ascites.

Monitor electrolytes. To correct further imbalances.