You are on page 1of 1

Assessment Subjective: I feel that my tummy is getting bigger as verbalized by the patient Objective: -weight gain -increasing abdominal

girth -dull to percussion, taut abdomen -beer belly Laboratory Result: -increase sodium (hyponatremia)=110 mEq /L -Albumin increase (hypoalbuminemia)= 2.9 g/dl Vital signs: T=37 P=80 bpm R= 21bpm BP= 130/80 mmHg

Nursing Diagnosis

Background Knowledge Excess fluid volume Chronic liver related to disease electrolyte develops imbalance and cardiovascular albuminemia as abnormalities manifested by due to an Ascites. increased cardiac output and decrease peripheral vascular resistance; possibly resulting from the release of vasodilator cirrhosis of the liver is a chronic disease that causes cell destruction and fibrosis (scaring) of hepatic tissue.

Planning After 3 days of applying appropriate interventions, the patients abdominal girth will decrease by 12 cm per day and peripheral edema will decrease.

Intervention -measure intake and output, weight daily and note weight gain more than 0.5 kg/day. -Restrict sodium and fluid as ordered.

Rationale -reflects circulating volume status. Positive balance/weight gain after reflects continuing fluid retention.

Evaluation Goal particularly met. After 3 days of applying appropriate nursing interventions, the patient abdominal girth decreased to 1-2 cm per day and peripheral edema decreased.

-Monitor blood pressure. -Compare current weight with admission and/or preciously stated weight. -Administer medication as ordered such as: diuretics. -Assist with paracentesis procedure. -Measure abdominal girth.

-Sodium may be restricted to minimize fluid retention in extravascular spaces. Fluid restriction may be increased necessary to prevent dilutional hyponatremia. -BP elevation usually associated with fluid volume excess. -To elevate degree of excess. -To control edema and ascites

-Prone to remove ascites fluid. -For changes that may indicate increasing fluid retention/edema.