Nursing Care Plan

CUES
Objective:
Limited
thoracic
expansion
Dyspnea
Crackles
heard upon
auscultation
on bilateral
lung fields
ascites

DIAGNOSIS
Ineffective
Breathing
Pattern r/t intraabdominal fluid
collection

OBJECTIVES
Short-term:
At the end of 30
minutes of nursing
intervention, the
patient will be able
to:
a) Maintain
effective
respiratory
pattern and
be free of
dyspnea and
cyanosis
b) Demonstrate
reduction of
congestion
with breath
sounds clear
and noiseless
respirations.
c) Demonstrate
behaviors to
improve and
maintain clear
airway

INTERVENTIONS
Independent:
a) Elevated head of
bed and position on
sides

b) monitor RR,
depth and effort;
auscultate breath
sounds, noting
crackles, wheezes
and ronchi

RATIONALE

EVALUATION

a) to take
advantage of
the gravity
decreasing
pressure on
the diaphragm
and to
minimize the
risk for
aspiration

Patient was able

to verbalize
relief of dyspnea
and is able to
maintain
respiratory rate
within normal
range

b) to watch out
for developing
complications
(ex. Presence
of adventitious
breath sounds
reflects
accumulation
of fluid or
secretions;
absent breath
sounds
suggests
atelectasis)

Long-term:
At the end of nursing
intervention and all
throughout the
course of treatment,
the patient will be
able to maintain
effective breathing
as evidenced by
absence of crackles
and signs of
respiratory distress

c) Instructed to
perform breathing
and coughing
exercises and
encourage frequent
repositioning

c) Facilitates
mobilization of
secretions and
aids in lung
expansion

d) Paced and
scheduled activities
providing adequate
rest periods.

d) This
prevents
dyspnea
resulting from
fatigue.

Dependent:
a) provide
supplemental
oxygen as needed

a) treats
hypoxia

b) assist in
respiratory adjuncts
(ex. Incentive
spirometer)

b) reduces
incidence of
atelectasis

c) assist in
paracentesis

c) removes
ascetic fluid

Nursing Care Plan

CUES
Objective:
Edema
Weight gain
Intake greater
than output
Oliguria
Dyspnea

DIAGNOSIS
Fluid Volume
Excess r/t
compromised
regulatory
mechanism

OBJECTIVES
Short-term:
At the end of 30
minutes of nursing
intervention, the
patient will be able
to:
a) Demonstrate
stabilized fluid
volume
b) Establish vital
signs within normal
range
Long-term:
At the end of nursing
intervention and all
throughout the
course of treatment,
the patient will be
able to have a
balance input and
output, manifest
absence of edema,
and maintain stable
weight.

INTERVENTIONS
Independent:
a) Measure I and O.
weigh daily and note
gain greater than
0.5 kg/day

RATIONALE

EVALUATION

a) Reflects
circulating
volume status
and continuing
fluid retention.

Patient was able

to verbalize
relief of dyspnea
and continues to
participate in
doing measures
to stabilize fluid
volume

b) Assess
respiratory status,
noting increase RR
and dyspnea

b) Indicates
pulmonary
congestion

c) Monitor for
cardiac
dysrhythmias and
auscultate heart
sounds

c) May be
caused by
heart failure or
electrolyte
imbalance

d) Encourage bed
rest

d) May
promote
recumbentinduced
diuresis

e) Limit fluid and

sodium intake as
indicated

e) Adds to
accumulation
of fluid

f) Provide frequent
oral care and
occasional ice chips

f) Decreases
sensation of
thirst

Dependent
a) Administer saltfree albumin or
plasma expanders
as indicated

a) Albumin may
be used to
increase the
colloid osmotic
pressure in the
vascular
compartment,
thereby
decreasing
formation of
ascites

b) Administer
Diuretics

b) Diuresis
treats fluid
retention

c) Implement
measures to prevent
skin breakdown

c) Edema
causes skin to
break down

Nursing Care Plan

CUES
Objective:
Fatigue
Weakness
Ascites
(abdominal
girth of 53cm)

DIAGNOSIS
Activity
Intolerance r/t
fatigue

OBJECTIVES
Short-term:
At the end of 30
minutes of nursing
intervention, the
patient will be able
to:

INTERVENTIONS
Independent:
a) Alternate rest and
activity

a) verbalize feeling
rested with fewer
complaints of fatigue

b) Monitor
hemoglobin and
hematocrit

b) allows
detection of
gastrointestinal
bleeding

c) Assist with
activities of daily
living

c) conserves
energy and
reduces
demands on
liver

d) Paced and
scheduled activities
providing adequate
rest periods.

d) This
prevents
dyspnea
resulting from
fatigue.

Long-term:
At the end of nursing
intervention and all
throughout the
course of treatment,
the patient will be
able to increase
tolerance in activity

Dependent:
a) Administer iron
supplements or
blood transfusions

RATIONALE
a) conserves
energy and
reduces
demands on
liver

a) Increases
activity
tolerance

EVALUATION
Patient was able
to verbalize
ways to
decrease
feelings of
fatigue and
weakness and
was able to
report fewer
complaints of
activity
intolerance.

as ordered.
b) Assist with
measures to
decrease edema
and ascites

b) increases
lung capacity