NAME: I.T.

AGE: 42 y.o. SEX: Male DATE OF ADMISSION: July 23, 2010

ATTENDING PHYSICIAN: Dr. Bonaobra
MEDICAL DIAGNOSIS: Liver Cirrhosis 2° Alcoholic Liver Disease: Anemia°

NURSING CARE PLAN

ASSESSMENT NURSING RATIONALE OBJECTIVES NURSING JUSTIFICATION EVALUATION

DIAGNOSIS INTERVENTION

Actual Excess fluid PREDISPO- PRESCIPI- After 4 days of Independent: After 4 days of
Abnormal Cues: volume related to SING TATING nursing 1. Measure 1. For changes that nursing
compromised FACTORS: FACTORS: intervention, the abdominal girth may indicate intervention:
 Na: 133 regulatory - Family history - lifestyle: client will be able increasing fluid
mmoL/L retention/edema
mechanism as - Age alcohol abuse to:
 Creatinine: evidenced by - Sex - stress 1. Goal met. The
1.31 mg/dl 2. Note fever 2. Client could be
edema, weight 1. Verbalize increased risk of client was able to
 Albumin: 2.89 gain and altered understanding of verbalize
mg/dl infection
electrolytes. individual understanding of
 Hemoglobin: dietary/fluid
86 3. To reduce tissue individual
Liver Cirrhosis restriction 3. Elevate edematous
 Hematocrit: pressure and risk dietary/fluid
extremities, change of skin
0.26 position frequently restriction
 Ascites breakdown
2. Perform
Impairs aldosterone 2. Goal met. The
exercises/ 4. To promote
Risk related metabolism and alters renal positioning to client was able to
4. Restrict sodium mobilization and
factors: perfusion reduce water perform
and fluid intake elimination
 Known alcohol retention exercises/
 user Definition: positioning to
Excess fluid Increase in salt and water reduce water
Weakness: volume retention (Pitting Edema Grade Collaborative: retention
 Financial - Increase 3) 1. Identify danger 1. To ensure timely
support signs requiring evaluation/interv
isotonic fluid
 Educational notification of ention
level retention
Excess fluid volume health provider
Strengths: 3. State the
importance of Source:
 Compliance to 3. Goal met. The
medication Source: positioning in a Nursing Care Plan
client was able to
 family support http://books.google.com.ph/boo modified Edition 7. (pgs.
importance of
trendelenberg. 468-469)
Source: ks?id=57RQC- positioning in a
Nurse’s Pocket 3OPtUC&pg=PT141&lpg=PT1 modified
Guide Edition 10 41&dq=pathophysiology+of+fl trendelenberg.
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