Assessment SUBJECTIVE: Napansin ko na lumalaki ang tiyan ko.

OBJECTIVE: Abdominal edema Pruritus noted With intact peritoneal wound dressing Weak and pale in appearance V/S taken as follows: T: 37.3 P: 105 R: 22 BP: 110/70

Explanation of the Problem Cirrhosis of

Objectives

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

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

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

After 8 hours of nursing the interventions, liver is a the patient chronic disease will that causes demonstrate cell stabilized destruction and fluid volume fibrosis and decreased (scarring) of edema. 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

Assess respiratory status, noting increased respiratory rate, dyspnea.

Indicative of pulmonary congestion.

Monitor blood pressure.

Blood pressure elevation usually associated with fluid volume excess but

Nursing Diagnosis: Fluid volume excess related to compromised regulatory mechanism

peritonitis, and hepatic encephalopathy.

may not occur because of fluid shifts out of the vascular space. Auscultate lungs, noting diminished/ absent breath sounds and developing adventitious sounds. Increasing pulmonary congestion may result in consolidatio n, impaired gas exchange, and complication s.

Measure abdominal girth.

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

Encourage bed rest when ascites is present.

May promote recumbencyinduced diuresis.

Administer medications as indicated. Such as diuretics. .

To control edema and ascites.