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 NURSING SCIENTIFIC PLANNING NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
Subjective: Fluid Volume Cirrhosis of the liver is a Short term:
Excess r/t chronic disease that ÀY After 8hours of
compromised causes cell destruction nursing ÀY Established rapport ÀY To gain trust and
regulatory and fibrosis *scarring* intervention the cooperation from the
Objectives: mechanism of the hepatic tissue. patient patient
ÀY Pallor secondary to Fibrosis alters normal willdemonstrate ÀY Êonitored vital signs ÀY To establish base line
ÀY Jeak in cirrhosis of the liver liver structure and stabilized fluid ÀY Êonitor ÔP data
appearance as manifested by vasculature , impairing volume and ÀY ÔP evaluation are
ÀY Abdominal pallor, weak in blood and lymph flow decreased edema usually associated with
distention noted appearance, and resulting in hepatic and abdominal fluid volume excess
ÀY Ôipedal edema-__ jaundice, insufficiency and girth ÀY Asses pulmonary status ÀY Indicative of pulmonary
ÀY Irritability noted abdominal hypertension in the congestion/edema
ÀY DOÔ with RR of distention, and portal vein. Long term: ÀY Êonitor abdominal girth ÀY Reflects accumulation
ÀY Abdominal girth of edema Complication include ÀY The patient will of fluid
37 inches hyponatremia, water manifest no sign ÀY Record accurate Intake and ÀY To monitor fluid
ÀY Jeight gain from / retention bleeding of edema and Output retention and kidney
__ to ___ esophageal varisces, abdominal function
ÀY Oliguria 
 
 coagulophaty, swelling ÀY Jeigh daily same time of ÀY Daily body weight is
3
 YY
3
 Y
ÀY Distended jugular 

 YY
spontaneous bacterial the day, on same scale with best monitor of fluid
vein  

  Y peritonitis and hepatic same equipment and status
ÀY Urea and Y   Y
Y encephalopathy. clothing
creatinine level  YY 3  3
Y
 
ÀY Changes in mental ÀY Restrict sodium and fluid as ÀY Sodium may be
status ordered restricted to minimize
ÀY ÔP- fluid retention in
ÀY Concentrated urine extravascular spaces.
Fluid restriction is
necessary to prevent
dilusional
hyponatremia
ÀY Change position of client ÀY To prevent pressure
timely ulcers
ÀY Review lab data like ÔUN, ÀY To monitor fluid and e-
Creatinine, Serum imbalances
electrolytes
ÀY Encourage quiet and restful ÀY To conserve energy
atmosphere and lower oxygen
ÀY Promote overall health demand
 measure
ÀY To promote wellness
Collaborative:
ÀY Furosemide
http://www.scribd.com/doc/26842154/E1-NPR-7-Fluid-Volume-Excess

http://www.scribd.com/doc/25847045/Fluid-Volume-Excess-CRF

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 NURSING DIAGNOSIS SCIENTIFIC EXPLANATION PLANNING NURSING INTERVENTION RATIONALE EVALUATION
Subjective: m  

3
 YY 3 3 YY Y

YY
 Y 3 YY   Y

Y  YY 3  Y
 Y3
Objectives:
ÀY Dyspnea /
ÀY Tachynpnea with RR of __,
irregular? Shallow? c



ÀY Jeak in appearance 




ÀY Irritability noted`  


 

ÀY Pallor





ÀY Use of accessory muscles

   
when breathing  



ÀY Crackles?rales?wheezing? 


ÀY Cough? 

ÀY Cyanosis in lip? And nailbeds?



ÀY Nasal flaring?   

ÀY  




 
 







 

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 NURSING DIAGNOSIS SCIENTIFIC EXPLANATION PLANNING NURSING INTERVENTION RATIONALE EVALUATION

c

 NURSING DIAGNOSIS SCIENTIFIC EXPLANATION PLANNING NURSING INTERVENTION RATIONALE EVALUATION