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NURSING CARE PLAN-1

Patient Name: - Rab Dino S/O Mola Bux Age: 50Y Sex: Male Ward No: 12 Bed No: 12 Marital Status: Married
Medical Diagnoses: Cirrhosis of the liver Address : SAKRAND OCCUPATION: Farmer Date: 19--03-2007

ASSESSMENT NURSING PLANNING INTERVENTION SCIENTIFIC RATIONALE EVALUATION


DIAGNOSIS
Fluid volume • After 8 hours of 1. Measure intake and 1. Reflects circulating After 8 hours of
SUBJECTIVE: excess nursing output, weigh daily, and volume status. Positive Nursing
I feel that my related to interventions, note weight gain more balance/ weight gain interventions,
tummy is compromise the patient will than 0.5 kg/day. often reflects continuing the
getting d demonstrate fluid retention. patient was
bigger) as regulatory stabilized fluid 2. Assess respiratory 2. Indicative of pulmonary able
verbalized by mechanism. volume and status, noting increased congestion. to demonstrate
the decreased respiratory rate, stabilized fluid
patient. edema. dyspnea. 3. Blood pressure volume and
3. Monitor blood pressure. elevation usually decreased
associated with fluid edema.
volume excess but may
not occur because of
fluid shifts out of the
4. Auscultate lungs, noting vascular space.
diminished/ absent 4. Increasing pulmonary
breath sounds and congestion may result in
developing adventitious consolidation, impaired
OBJECTIVE: sounds. gas exchange, and
• Anasarca complications.
• Weight gain 5. Assess degree of 5. Fluid shift into tissues
• Altered peripheral/ dependent as a result of sodium
electrolyte edema. and water retention,
levels decreased albumin, and
• Oliguria increased anti diuretic
• V/S taken as 6. Measure abdominal hormone (ADH).
follows: girth. 6. Reflects accumulation of
T: 37.3 fluid (ascites) resulting
P: 89 from loss of plasma
R: 20 proteins or fluid into
BP: 120/80 7. Encourage bed rest peritoneal space.
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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