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NCP Liver Cirrhosis

NCP Liver Cirrhosis

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Published by marlx5
tabled nursing care plan for liver cirrhosis
tabled nursing care plan for liver cirrhosis

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Published by: marlx5 on Aug 22, 2009
Copyright:Attribution Non-commercial

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02/07/2013

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ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:“Napansin ko nalumalaki angtiyan ko”(I feel that mytummy is gettingbigger)as verbalized bythe patient.OBJECTIVE:AnasarcaWeight gainAltered electrolytelevelsOliguriaV/S taken asfollows:T: 37.3P:89R: 20BP:120/80Fluid volumeexcessrelated tocompromised regulatorymechanism.Cirrhosis of the liveris a chronicdisease thatcauses celldestructionand fibrosis(scarring) of hepatictissue.Fibrosis altersnormal liverstructure andvasculature,impairingblood andlymph flowand resultingin hepaticinsufficiencyandhypertensionin the portalvein.Complicationsincludehyponatremia, waterretention,bleedingesophagealvarices.Coagulopathy, spontaneousbacterialAfter 8 hoursof nursinginterventions, the patientwilldemonstratestabilizedfluid volumeanddecreasededemaINDEPENDENT:Measure intake andoutput, weigh daily,and note weightgain more than 0.5kg/day.Assess respiratorystatus, notingincreasedrespiratory rate,dyspnea.Monitor bloodpressure.Auscultate lungs,noting diminished/absent breathsounds anddevelopingadventitious sounds.Assess degree of peripheral/dependent edema.Reflects circulatingvolume status.Positive balance/weight gain oftenreflects continuingfluid retention.Indicative of pulmonarycongestion.Blood pressureelevation usuallyassociated withfluid volume excessbut may not occurbecause of fluidshifts out of thevascular space.Increasingpulmonarycongestion mayresult inconsolidation,impaired gasexchange, andcomplications.Fluid shift intotissues as a resultof sodium andAfter 8 hours of nursinginterventions,the patient wasable todemonstratestabilized fluidvolume anddecreasededema.

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