NURSING CARE PLAN Patients Name: Mr. X Age: 52 y.

o Sex: Male Admitting Diagnosis: Ascites secondary to and LRTI Bacterial Date Assessment Need Nursing Background s Diagnosis Knowledge November Subjective: P Hepatitis is a medical 25, 2011 Daw may tubig bage ko H Y S Objective: - Jaundice noted - Jugular vein distention noted - Peripheral edema noted. - Ascites noted. - Use of sternocleidomastoid muscle when breathing observed. - Productive cough with whitish frothy secretions noted. -Capillary refill: 2 seconds - RR 26cpm - Crackles noted on N E E D I O L O G I C Impaired gas condition defined by exchange related to the inflammation of the liver and Date of Admission: November 16, 2011 Physician: Dr. B Room: Male Ward Planning Intervention with Rationale Independent: 1) Monitored vital signs especially the RR, including its depth, rate and rhythm. Evaluation

General: After 1 hour of nursing intervention pt will be relieved from signs of respiratory distress.

Goal partially met. After 1 hour of nursing intervention pts RR decreased from 26cpm to 22 cpm and use of accessory muscles are noted.

accumulation characterized by the of fluids on the right lung. presence of inflammatory cells in the tissue of the organ. Liver dysfunctions like hepatitis can lead to low albumin levels in blood. Albumin, produced only in the liver, is the major plasma protein that circulates in the bloodstream. Albumin is essential for maintaining the oncotic pressure in the vascular system.

useful in
evaluating the degree of

Specific: Will decrease RR from 26 cpm to 20cpm Presence of use accessory muscles will not be noted.

respiratory distress. 2) Auscultated both lungs.

breath sounds may

be faint because of decreased airflow or areas of consolidation.

3) Assessed capillary refill.

Capillary refill
indicate the

right lower lobe upon auscultation.

A decrease in oncotic pressure due to a low albumin level allows fluid to leak out to interstitial space,

adequacy of blood supply in the peripheries. 4) Maintained in semifowlers position.

- Laboratories: CXR- minimal pleural fluid right

peritoneal cavity and alveolar sacs; producing edema, ascites and pulmonary edema respectively. Thus, an impaired gas exchange occurs. References: Craig, R (2009), Hypoalbuminemia. Retrieved on November 30, 2011 from http://www.rnceus.co m/lf/lfalb.html.

Promotes lung
expansion. 5) Encouraged to expectorate phlegm.

prevents
accumulation of secretion within the airway. 6) Encouraged adequate rest periods and limit activities to client tolerance.

To decrease
oxygen tissue demand.

Brunner, S. (2009), What Is Pulmonary Edema? What Causes Pulmonary Edema? Retrieved on November 30, 2011 from http://www.medicalne wstoday.com/articles/

7) Provided a wellventilated environment.

Promotes an
environment

167533.php

conducive for rest.

Collaborative: 1) Administered mucolytic medication such as carbocisteine.

The drug
promotes expectoration of secretions.

NURSING CARE PLAN Patients Name: Mr. X Age: 52 y.o Sex: Male Admitting Diagnosis: Ascites secondary to and LRTI Bacterial Date Assessment Need Nursing Background s Diagnosis Knowledge Novem Subjective: P Hepatitis is a medical ber 25, Naghabok ang duwa 2011 ko nga tiil kag tiyan. H Y S Objective: - Jaundice noted - Jugular vein distention noted - Peripheral edema noted - Ascites noted - Crackles noted on right lower lobe upon auscultation. N E E D I O L O G I C Fluid volume condition defined by excess related to leakage of fluids in the interstitial the inflammation of the liver and characterized by the presence of inflammatory cells in Date of Admission: November 16, 2011 Physician: Dr. B Room: Male Ward Planning Intervention with Rationale Independent: 1) Monitored vital signs especially the PR, including its depth, rate and rhythm. Evaluation

General: After 8 hours of nursing intervention pt will participate fluid restriction measures.

Goal met. After 8 hours of nursing intervention patient participated in fluid restriction measures.

space due to the tissue of the decreased oncotic pressure. organ. Liver dysfunctions like hepatitis can lead to low albumin levels in blood. Albumin, produced only in the liver, is the major plasma protein that circulates in the bloodstream. Albumin is essential for maintaining the oncotic pressure in the vascular system.

Tachycardia
and increased blood pressure are seen in patients with fluid overload. 2) Monitor fluid intake and urinary output.

Specific: Prevent progression of the edema throughout the body.

Although overall
fluid intake may be adequate, shifting of fluid out of the intravascular

A decrease in oncotic pressure due to a low albumin level allows fluid to leak out to interstitial space, peritoneal cavity and alveolar sacs; producing edema, ascites and pulmonary edema respectively. Reference: Craig, R (2009), Hypoalbuminemia. Retrieved on November 30, 2011 from http://www.rnceus.co m/lf/lfalb.html.

to extravascular spaces may result in dehydration. 3) Instructed to avoid crossing of legs

Reduce
constriction of vessels thus preventing pooling. 4) Instructed to take low sodium foods and restrict fluid intake.

Sodium
promotes fluid retention and fluid intake restriction 5) Encouraged adequate rest periods and limit activities to client tolerance.

To conserve
oxygen and energy

consumption..

Collaborative: 1) Administered diuretic medication such as furosemide Rationale: Furosemide facilitates fluid excretion, thus increasing urinary output and helps decreasing fluid retention.