Student Nurses Community

NURSING CARE PLAN Liver Cirrhosis

ASSESSMENT
SUBJECTIVE:
Napansin ko na
lumalaki ang tiyan ko
as verbalized by the
patient.
OBJECTIVE:
Pallor
Weak in
appearance
Jaundice
Abdominal
distention noted
Bipedal edema
Irritability noted
DOB with RR of 29
bpm
Abdominal girth of
32

DIAGNOSIS

Fluid volume
excess r/t
compromised
regulatory
mechanism
secondary to
cirrhosis of the
liver as manifested
by pallor, weak in
appearance,
jaundice,
abdominal
distention, edema,
irritability, DOB
with RR of 29 and
abdominal girth of
32

PLANNING

After 6 hours of
nursing
interventions,
patient will
demonstrate
stabilized fluid
volume and
decreased
edema and
abdominal girth.

INTERVENTIONS
Monitor vital sign
Measure intake and
output
Monitor BP
Assess respiratory
status
Monitor abdominal
girth
Provide occasional
ice chips if NPO
Restrict sodium and
fluids as ordered
Administer
medications as
indicated:
Diuretics
Potassium
Assist with
paracentesis
procedure

RATIONALE

Established baseline data

Reflects circulating
volume status,
developing fluid shifts,
and in response to
therapy
BP elevations are usually
associated with fluid
volume excess
Indicative of pulmonary
congestion/edema
Reflects accumulation of
fluid (ascites)
Decreases sensation of
thirst, especially when
fluid intake is restricted
Sodium may be restricted
to minimize fluid
retention in extravascular
spaces. Fluid restriction
may be necessary to
prevent dilutional
hyponatremia
Used with caution to
control edema and
ascites, block effect of
aldosterone, and increase
water excretion while
sparing potassium
Serum and cellular
potassium are usually

EVALUATION

After 6
hours of nsg.
interventions,
the patient
demonstrated
stabilized fluid
volume and
decreased
edema and
abdominal
girth.
Goal met.

Student Nurses Community

depleted because of liver

disease
Done to remove ascites
fluid

Student Nurses Community

Nursing Care Plan

Assessment

Subjective: Wala akong

ganang kumain as
verbalized
Objective:
Weak in
appearance
Refusal to eat
Irritability noted
Poor muscle tone
Jaundice noted
Emaciated
Abdominal
distention noted
Pallor noted

Diagnosis

Imbalance
nutrition: less than
body requirements
r/t loss of appetite
secondary to
ascites as
evidenced by
refusal to eat,
weak in
appearance,
irritability, poor
muscle tone,
emaciated and
abdominal
distention

Planning

After 5 hrs of
nsg.
Interventions,
patients
appetite will
improve from 2
tbsp to at least 5
tbsp per meal.

Interventions

Monitor vital signs

Assist in oral hygiene

before meals.
Discuss eating habits
including food
preferences.
Serve favorite foods
that are not
contraindicated.
Prevent or minimize
unpleasant odors
during meal time.
Serve foods that are
attractive and
palatable.
Recommend small,
frequent meals
Restrict intake of
caffeine, gasproducing or spicy and
excessively hot or cold
foods
Provide assistance
with activities as
needed. Promote
undisturbed rest
periods, especially

Rationale

For baseline data

A clean mouth
enhances appetite
To appeal to client
likes and dislikes
To stimulate the
appetite
May have
negative effect on
appetite
To stimulate the
appetite
Poor tolerance to
larger meals may
be due to
increased intraabdominal
pressure/ascites
Aids in reducing
gastric irritation &
abdominal
discomfort that
may impair oral
intake/digestion
Conserving energy
reduces metabolic
demands on the
liver and promotes

Evaluation

After 8 hours of
nursing
interventions,
patients appetite
improved from 2
tbsp to 5 tbsp per
meal.
Goal met.

Student Nurses Community

before meals
Advise to consume
nutritious foods

cellular
regeneration.

Student Nurses Community

Nursing Care Plan

Assessment

Subjective:
Sumasakit ang tiyan
ko as verbalized with a
pain scale of 6 out of 10
where in:
0 - no pain
1 2 mild pain
3 4 moderate pain
5 6 severe pain
7 8 very severe pain
9 10 worst possible
Objective:
Facial grimace
noted
Irritability noted
Restlessness noted
Anxiety noted
Fatigued
Clenched fist
Beaten look
Agitation noted
Pallor
Grunting
Guarding of body
part (right
hypochondriac)

Diagnosis

Acute pain related

to liver
enlargement
secondary to
ascites as
evidenced by facial
grimace,
irritability,
restlessness,
anxiety, fatigued,
clenched fist,
beaten look,
agitation, pallor,
grunting, guarding
of body part and
verbalization of
pain with a pain
scale of 6/10

Planning

After 2 hours of
nursing
interventions,
pain will be
lessened with a
scale of 1-10,
from 6/10 to
1/10.

Interventions

Monitor VS
Perform pain
assessment
(COLDSPA) every
time pain occurs
Encourage
verbalization of
feeling of pain
Instruct use of
relaxation exercise
such as listening to
music
Provide comfort
measures such as
back rubbing &
changing position
Teach the patient
relaxation
techniques like deep
breathing
Provide quiet and
calm environment

Rationale

Pain alters VS
To rule out
development of
complications by
knowing alleviating
and precipitating
factors
Pain is subjective &
cant be assessed
through
observation alone
Promotes
relaxation and
diverts attention
from pain
To prove nonpharmacological
management
To alleviate pain
Noisy environment
stimulates
irritation

Evaluation

After 2 hours of
nursing
interventions,
patient was
relieved from pain
Goal met.

Student Nurses Community

Nursing Care Plan
ASSESSMENT
SUBJECTIVE:
Nahihirapan
akong huminga as
verbalized
OBJECTIVE:
Dyspnea
Tachypnea with RR
of 30, irregular,
shallow
Weak in
appearance
Anxiety noted
Irritability noted
Restlessness noted
Lethargic
Pallor

DIAGNOSIS

Altered breathing
pattern r/t
decreased lung
expansion
secondary to intraabdominal fluid
collection (ascites)
as manifested by
dyspnea,
tachypnea with RR
of 30, irregular and
shallow, weak in
appearance,
anxiety, irritability,
restlessness,
lethargy and pallor

PLANNING

INTERVENTIONS

After 6 hours of
nursing
interventions,
patient will be
relieved from
dyspnea and
breathing pattern
will return to
normal.

Monitor V/S
Monitor respiratory
rate, rhythm and
depth
Auscultate breath
sounds, noting
crackles, wheezes
and rhonchi
Investigate
changes in LOC
Keep head of bed
elevated. Position
on sides
Encourage
frequent
repositioning and
deep-breathing
exercises
Provide
supplemental O2
as indicated

RATIONALE

For baseline data

Rapid shallow
respirations/dyspn
ea may be present
because of hypoxia
or fluid
accumulation in
the abdomen
Indicates
developing
complications and
increasing risk of
infection
Changes in
mentation may
reflect hypoxemia
and respiratory
failure
Facilitates
breathing by
reducing pressure
on the diaphragm
Aids in lung
expansion and
mobilizing
secretions
May be necessary
to treat/prevent
hypoxia

EVALUATION

After 6 hours of
nsg. interventions,
patient was
relieved from
dyspnea and
breathing pattern
returned to normal
Goal met.

Student Nurses Community

Nursing Care Plan

ASSESSMENT
SUBJECTIVE:
Nanghihina na
ako, ayoko na
mag-gagalaw as
verbalized
OBJECTIVE:
Pallor
Body malaise
noted
Diaphoresis
Inability to
concentrate
Inability to perform
usual ADLs
Weak in
appearance
Limited ROM
Difficulty initiating
movements

DIAGNOSIS

Activity intolerance
r/t generalized
body weakness
secondary to
progressive
disease state as
manifested by
pallor, body
malaise,
diaphoresis,
inability to
concentrate,
inability to perform
usual ADLs, weak
in appearance,
limited ROM and
difficulty initiating
movements

PLANNING

INTERVENTIONS

After 8 hours of
nursing
interventions,
patient will
participate
willingly in
necessary activity,
will learn how to
conserve energy
and verbalize relief
from fatigue.

Evaluate pts
current activity
tolerance
Adjust activity and
reduce intensity of
task that may
cause undesired
physiological
changes
Increase exercise
and activity levels
gradually
Teach methods to
conserve energy
such as sitting
than standing
while dressing
Demonstrate/Assis
t the patient while
doing ADL
Give the patient
information that
provides evidence
progress
Encourage client to

RATIONALE

Provide
cooperative
baseline
To prevent over
exertion
Enhances activity
tolerance
Helps minimize
waste of energy
Protect patient
from injury
To sustain pts
motivation
Provides for sense
of control and
feeling of
accomplishment

EVALUATION

After 8 hours of
nursing
interventions,
patient participated
willingly in
necessary
activities, learned
how to conserve
energy and
verbalized relief
from fatigue
Goal met

Student Nurses Community

do whatever
possible e.g. selfcare

Student Nurses Community

Nursing Care Plan
ASSESSMENT
SUBJECTIVE:
Mawawala ba pa
tong laki ng tiyan
ko? as verbalized
OBJECTIVE:
Anxiety noted
Fear of rejection
Irritability noted
Restlessness noted
Feeling of
helplessness
Negative feelings
about body

DIAGNOSIS

Disturbed body
image r/t altered
physical
appearance as
evidenced by
anxiety, fear,
irritability,
restlessness,
feeling of
helplessness and
negative feelings
about the body

PLANNING

After 8 hours of
nursing
interventions,
patient will
verbalize
understanding of
changes and
acceptance of self
in the present
situation.

INTERVENTIONS

Discuss
situation/encourag
e verbalization of
fears and
concerns. Explain
relationship
between nature of
disease
and symptoms.

RATIONALE

Support and
encourage patient;
provide care with a
positive, friendly
attitude

Encourage family
to verbalize
feelings, visit
freely/participate
in care

Patient is very
sensitive to body
changes and may
also experience
feelings of guilt
when cause is
related to
alcohol (70%) or
other drug use.
Caregivers
sometimes allow
judgmental
feelings to affect
the care of patient
and need to make
every effort to help
patient feel valued
as a person.
Family members
may feel guilty
about patients
condition
and may be fearful
of impending death.
They need
nonjudgmental
emotional support
and free access to
patient.
Participation in care
helps them feel

EVALUATION

After 8 hours of
nursing
interventions,
patient verbalized
understanding of
changes and
acceptance of self
in the present
situation.
Goal met

Student Nurses Community

useful and
promotes trust
between staff,
patient.

Nursing Care Plan

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

Student Nurses Community

Subjective:
Lagi akong
nangangati at
parang mahapdi
balat ko as
claimed
Objective:
Pruritus noted
Dry skin
Erythema noted
Scaly skin

Risk for impaired

skin integrity r/t
altered circulation
secondary to
accumulation of
bile salts as
evidenced by
pruritus, erythema,
dry and scaly skin

After 7 hours of
nursing
interventions,
patient will
maintain skin
integrity and
identify individual
risk factors and
demonstrate
behaviors/techniqu
e to prevent skin
breakdown.

Inspect skin
surface/pressure
points routinely.
Gently massage
bony prominences
or areas of
continued stress

Encourage/assist
with repositioning
on a regular
schedule while in
bed, chair and
active passive
ROM exercises as
appropriate

Keep linen dry and

free of wrinkles

Suggest clipping
finger nails short

Edematous tissues
are more prone to
breakdown and to
the formation of
decubitus ulcers.
Ascites may
stretch the skin to
the point of tearing
in severe cirrhosis
Repositioning
reduces pressure
on edematous
tissues to improve
circulation.
Exercises enhance
circulation and
improve, maintain,
joint mobility
Moisture
aggravates
pruritus and
increases risk of
skin breakdown
Prevents client from
inadvertently
injuring the skin
especially while
sleeping

After 3 hours of
nursing
interventions,
patient maintained
skin integrity and
identified individual
risk factors and
demonstrated
behaviors/techniqu
es to prevent skin
breakdown.
Goal met

Student Nurses Community

Nursing Care Plan

Assessment

Subjective:
Nahiirapan akong
umihi as
verbalized
Objective:
Anxiety noted
Irritability noted
Restlessness noted
Small, frequent
voiding
Facial grimace
noted upon
urination
Excessive
diaphoresis when
trying to void
Urgency

Diagnosis

Impaired urinary
elimination r/t
bladder distention
secondary to
ascites as
evidenced by
anxiety, irritability,
restlessness, small
and frequent
voiding, facial
grimace upon
urination,
excessive
diaphoresis when
trying to void, and
urgency

Planning

After 8 hours of
nursing
interventions,
patient will empty
bladder regularly
with decrease pain
and difficulty.

Interventions

Rationale

Palpate bladder.
Investigate reports
of discomfort,
fullness, inability to
void

Provide routine
voiding measures
like privacy,
normal positioning,
running water in
sink, pouring warm
water over
abdomen

Perception of
bladder fullness,
distention of
bladder above
symphysis pubis
indicates urinary
retention
Promotes
relaxation urinary
muscles and may
facilitate voiding
efforts

Evaluation

After 8 hours of
nursing
interventions,
patient voided
regularly and
without difficulty.
Goal met

Student Nurses Community

Nursing Care Plan

Assessment

Subjective:
Anu kaya tong
sakit ko, san ko
nakuha to? as
verbalized
Objective:
Restlessness noted
Irritability noted
Confused look
Statement of
misconception
Development of
preventable
complications
Frequent questions

Diagnosis

Knowledge deficit
regarding
condition,
prognosis,
treatment and
discharge needs r/t
information
misinterpretation
as evidenced by
restlessness,
irritability,
confused look,
statement of
misconception,
development of
preventable
complications and
frequent questions

Planning

After 8 hours of
nursing
interventions,
patient will
verbalize
understanding of
disease process,
prognosis,
potential
complications and
identify necessary
lifestyle changes
and participate in
care.

Interventions

Review disease
process/prognosis
and future
expectations
Stress importance
of avoiding alcohol.
Give information
about community
services available
to aid in alcohol
rehabilitation if
indicated.
Emphasize the
importance of
good nutrition.
Recommendavoida
nce of highprotein/salty foods,
onions, and
strongcheeses.
Provide written
dietary instructions

Rationale

Provides
knowledge base
from which patient
can make informed
choices
Alcohol is the
leading cause in
the development
of cirrhosis
Proper dietary
maintenance and
avoidance of foods
highin sodium and
protein aid in
remission of
symptoms andhelp
prevent ammonia
buildup and further
liver
damage.Written
instructions are
helpful for patient
to refer to at home

Evaluation

After 8 hours of
nursing
interventions,
patient verbalized
understanding of
disease process,
prognosis, potential
complications and
identified
necessary lifestyle
changes and
participate in care.
Goal met

Student Nurses Community

Nursing Care Plan

Assessment

Subjective:
Hirap ako
makatulog as
claimed
Objective:
Sunken eyeballs
Fatigue
Mood alterations
Agitated
Body weakness
noted
Lethargic

Diagnosis

Disturbed sleep
pattern r/t changes
in activity pattern
secondary to
psychologic stress
as evidenced by
sunken eyeballs,
fatigue, mood
alterations,
agitation, body
weakness, lethargy

Planning

After 4 hours of
nursing
interventions,
patient will
establish adequate
sleep pattern and
report rested.

Interventions

Evaluate level of
stress

Rationale

Advise to reduce
fluid intake at
night

Increasing
confusion,
disorientation, and
uncooperative
behavior may
interfere with
attaining restful
sleep

Provide soft music

or white noise if
available

Decreases need to
get up to go to
bathroom during
sleep
Reduces sensory
stimulation by
blocking out other
environmental
sounds that could
interfere with restful
sleep

Evaluation

After 4 hours of
nursing
interventions,
patient established
adequate sleep
pattern and
reported rested.
Goal met