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    NCP 1

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    Denisse Shazz Mae Maret
    The patient presented with abdominal pain, constipation, bilateral leg edema, ascites, and absent peripheral pulses. Nursing interventions included monitoring vital signs and intake/output, daily weighing, abdominal girth measurements, edema assessments, and assisting with paracentesis if needed. The goals were to stabilize fluid volume, decrease edema and abdominal girth within 4 hours, and have the patient understand fluid restrictions and follow orders within 3 days. Interventions also included rest, sodium/fluid restriction, administering medications, and nutritional education.

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    NCP 1

    Uploaded by

    Denisse Shazz Mae Maret
    3K views5 pages
    The patient presented with abdominal pain, constipation, bilateral leg edema, ascites, and absent peripheral pulses. Nursing interventions included monitoring vital signs and intake/output, daily weighing, abdominal girth measurements, edema assessments, and assisting with paracentesis if needed. The goals were to stabilize fluid volume, decrease edema and abdominal girth within 4 hours, and have the patient understand fluid restrictions and follow orders within 3 days. Interventions also included rest, sodium/fluid restriction, administering medications, and nutritional education.

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    ncp 1

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    The patient presented with abdominal pain, constipation, bilateral leg edema, ascites, and absent peripheral pulses. Nursing interventions included monitoring vital signs and intake/output, daily weighing, abdominal girth measurements, edema assessments, and assisting with paracentesis if needed. The goals were to stabilize fluid volume, decrease edema and abdominal girth within 4 hours, and have the patient understand fluid restrictions and follow orders within 3 days. Interventions also included rest, sodium/fluid restriction, administering medications, and nutritional education.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    3K views5 pages

    NCP 1

    Uploaded by

    Denisse Shazz Mae Maret
    The patient presented with abdominal pain, constipation, bilateral leg edema, ascites, and absent peripheral pulses. Nursing interventions included monitoring vital signs and intake/output, daily weighing, abdominal girth measurements, edema assessments, and assisting with paracentesis if needed. The goals were to stabilize fluid volume, decrease edema and abdominal girth within 4 hours, and have the patient understand fluid restrictions and follow orders within 3 days. Interventions also included rest, sodium/fluid restriction, administering medications, and nutritional education.

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    © All Rights Reserved
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    Download as docx, pdf, or txt
    of 5

    ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

    DIAGNOSIS INTERVENTION
    SUBJECTIVE: Fluid volume SHORT TERM: INDEPENDENT: INDEPENDENT: SHORT TERM:
     Abdominal pain excess related After 4 hours of After 4 hours of
     Constipation to ascites and nursing  Complete vital  This will assess nursing
    edema interventions, signs if there are interventions,
    OBJECTIVE: formation as patient will and respiratory pulmonary goal partially
     Bilateral edema evidenced by demonstrate assessment congestions if met, patient
    was present on leg swelling. stabilized fluid there is a drop demonstrated
    both legs (+3) volume and in RR. An stabilized fluid
     severe ascites decreased increase in BP volume and
     notable edema and can be decreased
    absence of abdominal associated with edema and
    peripheral girth. fluid retention. abdominal
    pulses – Note impaired gas girth.
    dorsalis pedis LONG TERM : exchange and
    and posterior Within 3 days compromised LONG TERM:
    tibial. of giving respiratory Within 3 days
     Bowel sounds nursing function. Assess for of giving
    were present in interventions, decreased or labored nursing
    all 4 quadrants. the patient will breathing. interventions,
    be able to goal partially
     (+) dull
    perceive the  Measure intake  Reflects met, the patient
     tender to
    reason for fluid and output circulating was able to
    palpation
    restriction and volume status, perceive the
     irritable will be able to developing fluid reason for fluid
     facial grimace follow orders restriction and
    shifts, and in
     Vital Signs appropriately. response to able to follow
    BP: 110/64 mm/Hg therapy orders
    Temp: 97.7°F appropriately.
     Weight patient  To assess
    daily adequacy of
    Weight: 201 lb(91 kg)
    diet and
    measure the
    91 kg .
    BMI: use of diuretic
    5 72 (1.70 m )
    '
    therapy if
    utilized.
    = 31.48 Obese  Measure  This will allow a
    abdominal girth comparison to
    for baseline observe if there
    point if is an increase
    reference. or decrease in
    ascites. This
    measure the
    effectiveness of
    medical
    treatments.

     Assess level of  Edema allows


    edema from 1- health care
    4 and provider to
    documents assess if there
    finding is an excess 0n
    sodium intake
    or low serum
    albumin.
    Ascites is
    associated with
    low albumin
    levels.

     Assist with  If ascites


    paracentesis progresses, it
    as necessary may be
    necessary to
    perform
    paracentesis to
    drain the
    abdominal
    fluid. Assist
    with set-up and
    positioning of
    patient, post-
    procedure site
    assessments,
    and monitoring.

     Promote rest to  Impaired liver


    conserve function can
    energy cause the
    patient to be
    easily fatigued.
    Encourage rest
    periods and
    cluster care to
    conserve
    energy for
    nutrition and
    self-care.

     Restrict sodium  Sodium may be


    and fluids as restricted to
    ordered minimize fluid
    retention in
    extravascular
    spaces. Fluid
    restriction may
    be necessary
    to prevent
    dilutional
    hyponatremia

    DEPENDENT: DEPENDENT:
     Administer  Diuretics- are
    medications as often given to
    indicated: manage the
     Diuretics accumulation
     Lactulose of fluid and
     Analgesics edema
     Potassium  Lactulose- a
    man-made
    sugar that is
    given to help
    reduce the
    amount of
    ammonia in the
    blood and
    prevent hepatic
    encephalopath
    y
     Analgesics- gi
    ven to manage
    pain; avoid
    acetaminophen
     Potassium-
    Serum and
    COLLABORATIVE: cellular
     Provide potassium are
    adequate usually
    nutrition and depleted
    education, because of
    encourage liver disease
    lifestyle and urinary
    changes losses.

    COLLABORATIVE
     Malnutrition is
    often a
    complication
    of liver
    disease but
    may go
    unnoticed due
    to an increase
    in weight.
    Encourage
    and educate
    patients to
    maintain a
    diet low in
    sodium and
    fat. Avoid
    alcohol, seek
    treatment for
    alcohol
    dependence.  

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