Analisa Data

Data
Do :
1. Edema
2. hepatomegali
3. asites
4. ketidak seimbangan
elektrolit

Etiologi
Faktor predisposisi
Kerusakan hepatosit
Terbentuk jaringan parut
Sirosis hepatitis
Peregangan kapsula hati
Hepatomegali
Obstruksi vena porta
Peningkatan
resistensi
thd
aliran
darah
melalui
hati,
peningkatan
aliran
arteria
splangnikus

Gg. metabolisme
protein
sintesis plasma
protein (albumin)
hipoalbuminemia

Penurunan Aliran
vena hepatika,
peningkatan
aliran masuk

tekanan
hidrostatik
Penurunan
tekanan onkotik
plasma

Beban berlebihan
pada sistem
portal

Cairan berpindah
ke interstisial

(keridakseibangan
Hipertensi portal
Kelebihan Volume
cairan
elektrolit)
tekanan
hidrostatik di
sirkulasi portal
Cairan berpindah
dr sirkulasi portal

Expected Outcome

Masalah
Kelebihan
Volume
cairan

No
Indikator
1
Asites
2
Peningkatan ukuran abdomen
3
Penurunan urine output
NOC : Fluid Overload Severity

V
V
V

Keterangan :
1 = severe
2 = substantially
3 = moderately
4= mild
5 =none
NOC : Fluid Balance
N

Indikator

o
1
Kestabilan berat badan
2
Serum elektrolit (sodium, potassium)
Keterangan :

V
V

1 = severity compromised
2 = substantially compromised
3= moderately compromised
4=mildly compromised
5=not compromised

Nursing Interventions
1. Restrict sodium and uid intake if prescribed. (Electrolyte monitoring: 167)
Provide diet appropriate for patient electrolyte in balance (potassium-rich foods
or low sodium diet)
2. Administer diuretics, potassium, and protein supplements as prescribed. (Fluid

Management: 200 )
administer prescribed diuretics, as appropriate
3. Record intake and output every 1 to 8 h depending on response to interventions
and on patient acuity. (Fluid Monitorting: 200)
keep an accurate record of intake and output
4. Measure and record abdominal girth and weight daily.(Peritoneal Dyalisis
Therapy 295)
Measure and record abdominal girth
Measure and record daily weight
5. Explain rationale for sodium and uid restriction. (Fluid/electrolyte Management:
199)
Instruct patient and family about rationale for fluid restriction
6. Prepare patient and assist with paracentesis. (Fluid/electrolyte Management:
199)
Prepare patient for dyalisis