Nursing Care Plan

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective: “Napansin  Fluid volume  After 6 hours of  Monitor vital sign  Established  After 6 hours of
ko na lumalaki ang excess r/t nursing baseline data nsg. interventions,
tiyan ko” as verbalized compromised interventions,  Measure intake  Reflects circulating the patient
Objective: regulatory patient will and output volume status, demonstrated
 Pallor mechanism demonstrate developing fluid stabilized fluid
 Weak in secondary to stabilized fluid shifts, and in volume and
appearance cirrhosis of the volume and response to decreased edema
 Jaundice liver as manifested decreased edema  Monitor BP therapy and abdominal
 Abdominal by pallor, weak in and abdominal  BP elevations are girth.
distention noted appearance, girth. usually associated
 Bipedal edema jaundice, with fluid volume Goal met.
abdominal  Assess respiratory excess
 Irritability noted
distention, edema, status  Indicative of
 DOB with RR of 29
irritability, DOB pulmonary
bpm
with RR of 29 and  Monitor abdominal congestion/edema
 Abdominal girth of abdominal girth of
32” girth  Reflects
32” accumulation of
 Provide occasional
ice chips if NPO fluid (ascites)
 Decreases
sensation of thirst,
 Restrict sodium especially when
and fluids as fluid intake is
ordered restricted
 Sodium may be
restricted to
minimize fluid
retention in
extravascular
spaces. Fluid
 restriction may be
 Administer necessary to
medications as prevent dilutional
indicated: hyponatremia
• Diuretics

 Used with caution

to control edema
and ascites, block
• Potassium effect of
aldosterone, and
increase water
excretion while
 Assist with sparing potassium
paracentesis  Serum and cellular
procedure potassium are
usually depleted
because of liver
disease
 Done to remove
ascites fluid
 Nursing Care Plan

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective: “Wala akong  Imbalance  After 5 hrs of nsg.  Monitor vital signs  For baseline data  After 8 hours of
ganang kumain” as nutrition: less than Interventions, nursing
verbalized body requirements patient’s appetite  Assist in oral  A clean mouth interventions,
r/t loss of appetite will improve from 2 hygiene before enhances appetite patient’s appetite
Objective: secondary to tbsp to at least 5 meals.  To appeal to client improved from 2
 Weak in ascites as tbsp per meal.  Discuss eating likes and dislikes tbsp to 5 tbsp per
appearance evidenced by habits including meal.
 Refusal to eat refusal to eat, food preferences.  To stimulate the
 Irritability noted weak in  Serve favorite appetite Goal met.
 Poor muscle tone appearance, foods that are not
 Jaundice noted irritability, poor contraindicated.  May have negative
muscle tone, Prevent or effect on appetite
 Emaciated 
emaciated and minimize
 Abdominal
abdominal unpleasant odors
distention noted  To stimulate the
distention during meal time.
 Pallor noted appetite
 Serve foods that
are attractive and  Poor tolerance to
palatable. larger meals may
 Recommend small, be due to
frequent meals increased intra-
abdominal
pressure/ascites
 Aids in reducing
 Restrict intake of gastric irritation &
caffeine, gas- abdominal
producing or spicy discomfort that
and excessively may impair oral
hot or cold foods intake/digestion
 Provide assistance  Conserving energy
with activities as reduces metabolic
needed. Promote demands on the
undisturbed rest liver and promotes
periods, especially cellular
before meals regeneration.
 Advise to consume
nutritious foods
 Nursing Care Plan

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective:  Acute pain related  After 2 hours of  Monitor VS  Pain alters VS  After 2 hours of
“Sumasakit ang tiyan to liver nursing  Perform pain  To rule out nursing
ko” as verbalized with a enlargement interventions, assessment development of interventions,
pain scale of 6 out of 10 secondary to pain will be (COLDSPA) every complications by patient was
where in: ascites as lessened with a time pain occurs knowing alleviating relieved from pain
0 - no pain evidenced by facial scale of 1-10, and precipitating
1 – 2 mild pain grimace, from 6/10 to factors Goal met.
3 – 4 moderate pain irritability, 1/10.  Pain is subjective &
5 – 6 severe pain restlessness,  Encourage can’t be assessed
7 – 8 very severe pain anxiety, fatigued, verbalization of through
9 – 10 worst possible clenched fist, feeling of pain observation alone
“beaten” look,  Promotes
Objective: agitation, pallor, relaxation and
 Facial grimace grunting, guarding  Instruct use of diverts attention
noted of body part and relaxation exercise from pain
 Irritability noted verbalization of such as listening to  To prove non-
 Restlessness noted pain with a pain music pharmacological
 Anxiety noted scale of 6/10  Provide comfort management
 Fatigued measures such as
 Clenched fist back rubbing &  To alleviate pain
 “Beaten” look changing position
 Agitation noted  Teach the patient
 Pallor relaxation  Noisy environment
 Grunting techniques like deep stimulates
breathing irritation
 Guarding of body
part (right  Provide quiet and
hypochondriac) calm environment
 Nursing Care Plan

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective:  Altered breathing  After 6 hours of  Monitor V/S  For baseline data  After 6 hours of
 “Nahihirapan pattern r/t nursing  Monitor respiratory  Rapid shallow nsg. interventions,
akong huminga” as decreased lung interventions, rate, rhythm and respirations/dyspn patient was
verbalized expansion patient will be depth ea may be present relieved from
secondary to intra- relieved from because of hypoxia dyspnea and
Objective: abdominal fluid dyspnea and or fluid breathing pattern
 Dyspnea collection (ascites) breathing pattern accumulation in returned to normal
 Tachypnea with RR as manifested by will return to  Auscultate breath the abdomen
of 30, irregular, dyspnea, normal. sounds, noting  Indicates Goal met.
shallow tachypnea with RR crackles, wheezes developing
 Weak in of 30, irregular and and rhonchi complications and
appearance shallow, weak in  Investigate increasing risk of
 Anxiety noted appearance, changes in LOC infection
anxiety, irritability,  Changes in
 Irritability noted
restlessness, mentation may
 Restlessness noted
lethargy and pallor  Keep head of bed reflect hypoxemia
 Lethargic
elevated. Position and respiratory
 Pallor
on sides failure
 Encourage  Facilitates
frequent breathing by
repositioning and reducing pressure
deep-breathing on the diaphragm
exercises  Aids in lung
 Provide expansion and
supplemental O2 mobilizing
as indicated secretions

 May be necessary
to treat/prevent
 hypoxia

Nursing Care Plan

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective:  Activity intolerance  After 8 hours of  Evaluate pt’s  Provide  After 8 hours of
 “Nanghihina na r/t generalized nursing current activity cooperative nursing
ako, ayoko na body weakness interventions, tolerance baseline interventions,
mag-gagalaw” as secondary to patient will  Adjust activity and  To prevent over patient
verbalized progressive participate reduce intensity of exertion participated
disease state as willingly in task that may willingly in
Objective: manifested by necessary activity, cause undesired necessary
 Pallor pallor, body will learn how to physiological activities, learned
 Body malaise malaise, conserve energy changes  Enhances activity how to conserve
noted diaphoresis, and verbalize relief  Increase exercise tolerance energy and
 Diaphoresis inability to from fatigue. and activity levels verbalized relief
 Inability to concentrate, gradually  Helps minimize from fatigue
concentrate inability to perform  Teach methods to waste of energy
usual ADLs, weak conserve energy Goal met
 Inability to perform
in appearance, such as sitting
usual ADLs
limited ROM and than standing
 Weak in
difficulty initiating while dressing  Protect patient
appearance
movements  Demonstrate/Assis from injury
 Limited ROM
 Difficulty initiating t the patient while
movements doing ADL  To sustain pt’s
 Give the patient motivation
information that
provides evidence
progress  Provides for sense
 Encourage client to of control and
do whatever feeling of
possible e.g. self- accomplishment
care
 Nursing Care Plan

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective:  Disturbed body
 “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
 After 8 hours of  Discuss  Patient is very  After 8 hours of
image r/t altered nursing situation/encourag sensitive to body nursing
physical interventions, e verbalization of changes and may interventions,
appearance as patient will fears and also experience patient verbalized
evidenced by verbalize concerns. Explain feelings of guilt understanding of
anxiety, fear, understanding of relationship when cause is changes and
irritability, changes and between nature of related to acceptance of self
restlessness, acceptance of self disease alcohol (70%) or in the present
feeling of in the present and symptoms. other drug use. situation.
helplessness and situation.  Caregivers
negative feelings  Support and sometimes allow Goal met
about the body encourage patient; judgmental
provide care with a feelings to affect
positive, friendly the care of patient
attitude and need to make
every effort to help
patient feel valued
as a person.
 Encourage family  Family members
to verbalize may feel guilty
feelings, visit about patient’s
freely/participate condition
in care and may be fearful
of impending death.
They need
nonjudgmental
emotional support
and free access to
patient.
Participation in care
 helps them feel
useful and
promotes trust
between staff,
patient.

Nursing Care Plan

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective:  Risk for impaired  After 7 hours of  Inspect skin  Edematous tissues  After 3 hours of
 “Lagi akong skin integrity r/t nursing surface/pressure are more prone to nursing
nangangati at altered circulation interventions, points routinely. breakdown and to interventions,
parang mahapdi secondary to patient will Gently massage the formation of patient maintained
balat ko” as accumulation of maintain skin bony prominences decubitus ulcers. skin integrity and
claimed bile salts as integrity and or areas of Ascites may identified
evidenced by identify individual continued stress stretch the skin to individual risk
Objective: pruritus, erythema, risk factors and the point of tearing factors and
 Pruritus noted dry and scaly skin demonstrate in severe cirrhosis demonstrated
 Dry skin behaviors/techniqu  Repositioning behaviors/techniqu
 Erythema noted e to prevent skin  Encourage/assist reduces pressure es to prevent skin
 Scaly skin breakdown. with repositioning on edematous breakdown.
on a regular tissues to improve
schedule while in circulation. Goal met
bed, chair and Exercises enhance
active passive circulation and
ROM exercises as improve, maintain,
appropriate joint mobility
 Moisture
 Keep linen dry and aggravates
free of wrinkles pruritus and
increases risk of
skin breakdown
 Suggest clipping  Prevents client from
finger nails short inadvertently
injuring the skin
especially while
sleeping
 Nursing Care Plan

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective:  Impaired urinary  After 8 hours of  Palpate bladder.  Perception of  After 8 hours of
 “Nahiirapan akong elimination r/t nursing Investigate reports bladder fullness, nursing
umihi” as bladder distention interventions, of discomfort, distention of interventions,
verbalized secondary to patient will empty fullness, inability to bladder above patient voided
ascites as bladder regularly void symphysis pubis regularly and
Objective: evidenced by with decrease pain indicates urinary without difficulty.
 Anxiety noted anxiety, irritability, and difficulty. retention
 Irritability noted restlessness, small  Provide routine  Promotes Goal met
 Restlessness noted and frequent voiding measures relaxation urinary
 Small, frequent voiding, facial like privacy, muscles and may
voiding grimace upon normal positioning, facilitate voiding
urination, running water in efforts
 Facial grimace
excessive sink, pouring warm
noted upon
diaphoresis when water over
urination
trying to void, and abdomen
 Excessive
urgency
diaphoresis when
trying to void
 Urgency
 Nursing Care Plan

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective:  Knowledge deficit  After 8 hours of  Review disease  Provides  After 8 hours of
 “Anu kaya ‘tong regarding nursing process/prognosis knowledge base nursing
sakit ko, san ko condition, interventions, and future from which patient interventions,
nakuha to?” as prognosis, patient will expectations can make informed patient verbalized
verbalized treatment and verbalize  Stress importance choices understanding of
discharge needs r/t understanding of of avoiding alcohol.  Alcohol is the disease process,
Objective: information disease process, Give information leading cause in prognosis,
 Restlessness noted misinterpretation prognosis, about community the development potential
 Irritability noted as evidenced by potential services available of cirrhosis complications and
 Confused look restlessness, complications and to aid in alcohol identified
 Statement of irritability, identify necessary rehabilitation if necessary lifestyle
misconception confused look, lifestyle changes indicated. changes and
statement of and participate in  Emphasize the participate in care.
 Development of
misconception, care. importance of  Proper dietary
preventable
development of good nutrition. maintenance and Goal met
complications
preventable Recommendavoida avoidance of foods
 Frequent questions
complications and nce of high- highin sodium and
frequent questions protein/salty foods, protein aid in
onions, and remission of
strongcheeses. symptoms andhelp
Provide written prevent ammonia
dietary instructions buildup and further
liver
damage.Written
instructions are
helpful for patient
to refer to at home
 Nursing Care Plan

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective:  Disturbed sleep  After 4 hours of  Evaluate level of  Increasing  After 4 hours of
 “Hirap ako pattern r/t changes nursing stress confusion, nursing
makatulog” as in activity pattern interventions, disorientation, and interventions,
claimed secondary to patient will uncooperative patient established
psychologic stress establish adequate behavior may adequate sleep
Objective: as evidenced by sleep pattern and interfere with pattern and
 Sunken eyeballs sunken eyeballs, report rested.  Advise to reduce attaining restful reported rested.
 Fatigue fatigue, mood fluid intake at sleep
 Mood alterations alterations, night  Decreases need to Goal met
 Agitated agitation, body get up to go to
weakness, lethargy  Provide soft music bathroom during
 Body weakness
or “white noise” if sleep
noted
available  Reduces sensory
 Lethargic
stimulation by
blocking out other
environmental
sounds that could
interfere with restful
sleep