Assessment SUBJECTIVE: Napansin ko na lumalaki ang tiyan ko as verbalized by the patient.

OBJECTIVE: Anasarca Weight gain Altered electrolyte levels V/S taken as follows: T- 37.6 C P- 110 R-29 BP- 180/100

Diagnosis Fluid volume excess related to compromised regulatory mechanism as evidenced by edema and ascites formation

Planning After 8 hours of nursing interventions,the patient will demonstrate stabilized fluid volume and decreased edema.

Intervention INDEPENDENT: > Measure intake and output,weigh daily, andnote weight gainmore than 0.5kg/day. > Assess respiratory status, noting increased respiratory rate, dyspnea. >Monitor blood pressure. Auscultate lungs, noting diminished/ absent breath sounds and developing adventitious sounds. >Assess degree of peripheral/ dependent edema.

Rationale >Reflects circulating volume status. Positive balance/ weight gain often reflects continuing fluid retention. > Indicative of pulmonary congestion. >Blood pressure elevation usually associated with fluid volume excess but may not occur because of fluid shifts out of the vascular space. >Increasing pulmonary congestion may result in consolidation, impaired gas

Evaluation Goal met. After 8 hours of Nursing interventions, the patient was able to demonstratestabilized fluid volume and decreased edema.

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: Mabigat at masakit ang tyan ko as verbalized by the patient. Objective: >facial grimace >with a painscale of 6/10 >irritable >with guarding behavior >with massive ascites

Acute pain and discomfort related to enlarged tender liver and ascites as evidenced by facial grimace and painscale of 6/10.

After 8 hours of effective nursing intervention, the patient will be able to demonstrate divertional activities to lessen pain.

INDEPENDENT: 1. Maintain bed rest when patient experiences abdominal discomfort. 2. Observe, record, and report presence and character of pain and discomfort.

1. Reduces metabolic demands and protects the liver.

2. Provides baseline to detect further deterioration of status and to evaluate interventions. 3. Reduce 3. Minimizes sodium and further fluid intake if formation of prescribed. ascites. 4. Teach patient divertional 4. Provide activities such venous return as deep and promotes breathing relaxation to excercises and the patient. provide reading materials. 5. Prepare patient and 5. Removal of assist with ascites fluid paracentesis. may decrease DEPENDENT: abdominal 6.Administer discomfort.

Goal met. After 8 hours of effective nursing intervention, patient seen doing the divertional activities instructed and patients pain lessened from 6/10 to 4/10.

antispasmodic and sedative agents as prescribed.

6. Reduces irritability of the gastrointestinal tract and decreases abdominal pain and discomfort.

Assessment Madalas akong hapuin lalo na kapag lagi nakahiga as verbalized by

Diagnosis Impaired Gas Exchange r/t accumulation of fluid in pleural space

Planning After 8 hours of giving effective nursing intervention and health

Intervention INDEPENDENT : 1. Position client in either

Rationale

1. Promote good ventilatio

Evaluation Goal met. After 8 hours of giving effective nursing intervention and health

the patient. Objective: >Use of accessory muscles when breathing >with labored breathing (shallow breathing) RR- 29 cycles per minute (+) crackles

secondary to underlying physiologic condition.

teaching, the patient will be able to know positioning techniques that improve ventilation.

semifowlers position or side lying position. 2. Encourag e client to cough as tolerated.

n and teaching, the breathing. patient was able to know 2. Will positioning promote techniques that mucoid or improve sputum ventilation. excretion from the lungs 3. Proper assessme nt will help identify early problems.

3. Monitor respirator y rate, depth, and effort, including use of accessory muscles, nasal flaring, and thoracic or abdomina l breathing.

4. Changes in behavior and mental status can be early signs of impaired gas

exchange. 4. Monitor clients behavior and mental status for onset of restlessne ss, agitation, confusion and in the late stages, extreme lethargy 5. Observe for cyanosis in skin: note especial color of tongue and oral mucous membran e.

5. Central cyanosis in tongue and oral mucosa is indication of serious hypoxia and is a medical emergenc y; peripheral cyanosis seen in extremitie s may not be serious. 1. To promote enough oxygen

supply Dependent: 1. Administe r oxygen inhalation appropriat ely. 2. Administe r salbutam ol 2. To provide bronchodi lation.

Subjective: Nahihirapan akong huminga, as verbalized by the patient. Objective: >flaring of nose >inadequate chest expansion >rapid shallow breathing >pallor V/S T- 37.6 C P- 110 R-29 BP- 120/90

Ineffective breathing pattern related to intra-abdominal fluid collection as evidenced by rapid shallow breathing.

After 8-hours of nursing intervention the patient will participate in actions to maximize oxygenation.

Independent: 1. Monitor respiratory rate, depth and effort.

2. Auscultate breath sounds, noting crackles, wheezes or ronchi.

1. Rapid shallow breathing may be present because of hypoxia and fluid accumulation in the abdomen. 2. Indicates developing of complications (adventitious sounds reflects accumulation of fluid; absent sounds suggest atelectasis. 3. Changes in mentation may reflect hypoxemia and respiratory failure which often accompany hepatic coma. 4. Facilitates breathing by reducing pressure on the diaphragm and minimizes risk of aspiration of secretions.

Goal met. After 8 hours of nursing intervention the patient participate in deep breathing and coughing exercises.

3. Investigate changes in the level of consciousness.

4. Keep head of the bed elevated.

5. Frequent repositioning and encourage deepbreathing exercises or coughing as appropriate. 6. Monitor