NURSING CARE PLAN-1 Patient Name: - Rab Dino S/O Mola Bux Age: 50Y Medical Diagnoses: Cirrhosis of the

liver ASSESSMENT NURSING DIAGNOSIS Fluid volume SUBJECTIVE: excess I feel that my related to tummy is compromise getting d bigger) as regulatory verbalized by mechanism. the patient. PLANNING • After 8 hours of nursing interventions, the patient will demonstrate stabilized fluid volume and decreased edema.

Sex: Male Ward No: 12 Bed No: 12 Marital Status: Married Address : SAKRAND OCCUPATION: Farmer Date: 19--03-2007 INTERVENTION SCIENTIFIC RATIONALE EVALUATION After 8 hours of Nursing interventions, the patient was able to demonstrate stabilized fluid volume and decreased edema.

1. Measure




OBJECTIVE: • Anasarca • Weight gain • Altered electrolyte levels • Oliguria • V/S taken as follows: T: 37.3 P: 89 R: 20 BP: 120/80




intake and 1. Reflects circulating output, weigh daily, and volume status. Positive note weight gain more balance/ weight gain than 0.5 kg/day. often reflects continuing fluid retention. Assess respiratory 2. Indicative of pulmonary status, noting increased congestion. respiratory rate, dyspnea. 3. Blood pressure Monitor blood pressure. elevation usually associated with fluid volume excess but may not occur because of fluid shifts out of the vascular space. Auscultate lungs, noting diminished/ absent 4. Increasing pulmonary breath sounds and congestion may result in developing adventitious consolidation, impaired sounds. gas exchange, and complications. Assess degree of 5. Fluid shift into tissues peripheral/ dependent as a result of sodium edema. and water retention, decreased albumin, and increased anti diuretic hormone (ADH). Measure abdominal girth. 6. Reflects accumulation of fluid (ascites) resulting from loss of plasma proteins or fluid into peritoneal space. Encourage bed rest when ascites is present. 7. May promote recumbency induced diuresis.

Reference: Carpenito. L .J. (1995). Nursing Diagnosis (6th Ed.), New Jersey J.B.Lippincott Company. Student name: BHERU LAL Discipline B.Sc. N-1(2007-9)

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