NURSING CARE PLAN
1. Fluid Volume excess related to compromised regulatory mechanism 2. Impaired skin integrity related to altered circulation 3. Activity intolerance related to fatigue
RATIONALE OBJECTIVES Short Term: NSG. INTERVENTION Independent: RATIONALE EVALUATION Short Term:
ASSESSMENT Subjective: Namamanas yung katawan ko, dahil yan sa problema ko sa liver. as verbalized by the patient
NSG. DIAGNOSIS P - Fluid Volume Excess
E - Related to compromised regulatory mechanism
Objective: Pallor Edema (Upper & Lower extremities) Orthopnea Rapid weight gain Restlessness and anxious Weak in appearance
S - As manifested by: Namamanas yung katawan ko, dahil yan sa problema ko sa liver. as verbalized by the patient
Palor Edema (Upper &
A liver dysfunction causes cell destruction and fibrosis (scarring) of hepatic tissue. Fibrosis alters normal liver structure and vasculature, impairing blood and lymph flow and resulting in hepatic insufficiency and hypertension in the portal vein. and this may lead to hepatic encephalopathy thus, the bodys regulatory function is
After 30mins-1hr of nursing intervention the patient will be able to:
1. Help patient into a position that aids breathing such as fowlers or semi fowlers position
To increase chest expansion and improve ventilation
After 1 hour of nursing intervention the patient was able to: Lists signs and symptoms that
1. Describe signs and symptoms that require medical treatment & demonstrate skill in selecting permitted foods such as low in sodium
2. Measure and record vital signs at least every 1 hour
Changes may indicate fluid or electrolyte imbalances
require medical attention & plans own menu and selects food low in sodium
3. Weigh patient at the 2. Tolerate restricted intake with no emotional discomfort. same time and weighing scale each day
To obtain consistent readings
Tolerate restricted intake and verbalization of binabawasan ko na ang
Long term:
4. Assess patient daily for edema
Fluid overload or decreased osmotic pressure may result in
paginom ng marami
After 3-8 hours of nursing intervention the
GOAL: partially met
NURSING CARE PLAN
Lower extremities) Orthopnea Rapid weight gain Restlessness and anxious Weak in appearance
1. Fluid Volume excess related to compromised regulatory mechanism 2. Impaired skin integrity related to altered circulation 3. Activity intolerance related to fatigue
patient will be able to: edema especially in dependent 1. Assist with activities of daily living without undue fatigue & maintain desirable daily fluid intake 1. Administer diuretics as prescribed by the 2. Stabilized fluid volume and normal body function as evidenced by: 2. Maintain the patient on sodium and water restricted as (-) Palor Decreased edema (Upper & Lower extremities) (-) Orthopnea Normal weight gain Absence of restlessness and anxious Not weak in appearance Collaborative: 1. Administer oxygen as ordered. To enhance arterial blood oxygenation (-) Pallor Absence of restlessness and anxious Not weak in appearance GOAL: partially met ordered To reduce excess fluid and prevent reaccumulations - Stabilized normal body function as evidenced by: physician Promotes water and sodium excretion. Dependent: areas After 6 hours of nursing intervention the client was able to: - Performed daily living without undue fatigue while assisting & maintained desirable daily fluid intake Long term:
altered and will not be able to regulate body fluids, patient may manifest edema and increase in weight gain.
Reference: http://healthmad. com/conditionsanddiseases/liver dysfunction /
Reference: Sparks and taylors th reference manual 6 edition p.112-116
NURSING CARE PLAN
1. Fluid Volume excess related to compromised regulatory mechanism 2. Impaired skin integrity related to altered circulation 3. Activity intolerance related to fatigue
