ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTIONS

RATIONALE

S: Wala akong
ganang kumain
at wala pang
kalahating plato
ng pagkain
nauubos ko kasi
pakiramdam ko
busog ako, as
verbalized by the
client.
O:
- abdominal
enlargement
(abdominal girth
of 95cm)
- poor muscle
tone
- weakness
- weight loss
- rbc 3.71 (low)
- hgb 104 (low)
- BMI:
underweight
weight: 52 kilos
height: 17.9

Imbalanced
nutrition: less
than body
requirements
related to
increased
pressure on
stomach and
intestines as
feeling of
fullness, poor
appetite as
evidenced by
body weakness
and poor muscle
tone

After 2 days
of nursing
interventions,
the patient
will
demonstrate
behaviors,
lifestyle
changes to
regain and
maintain
appropriate
weight

- Discussed eating
habits, including food
preferences,
intolerances or
aversions

-To appeal to clients

tastes

Assisted/encouraged
patient to eat;
explain reasons for
the types of diet.
Feed patient if tiring
easily, or have SO
assist patient.
Consider preferences
in food choices
Recommended/provi
ded small, frequent
meals

- Promoted pleasant,
relaxing
environment,
including

- Improved
nutrition/diet is vital
to recovery. Patient
may eat better if
family is involved and
preferred foods are
included as much as
possible
- Poor tolerance to
larger meals may be
due to increased
intra-abdominal
pressure/ascites
- To enhance food
intake

- Patient is prone to
sore and/or bleeding

EVALUATI
ON
After 2 days
of nursing
intervention
s, the
displayed
good
appetite
and
interest in
food by
eating
almost of
his food.

socialization when
possible
- Encouraged
frequent mouth care,
especially before
meals

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION
S

gums and bad taste

in mouth, which
contributes to
anorexia

RATIONALE

EVALUATION

S: May time na
hinahabol ko ang
paghinga ko,
katulad ngayon
as verbalized by
the client.
O:
- Rapid shallow
respirations
-Shortness of
breath
- Orthopnea
-Use of
accessory
muscles to
breathe
- RR: 24

Ineffective
Breathing
Pattern r/t
pressure on the
diaphragm
caused by intraabdominal fluid
collection as
evidenced by
rapid shallow
respirations, and
orthopnea

After 30 minutes
of nursing
interventions,
the client will
establish a
normal, effective
respiratory
pattern

- Auscultated
breath sounds,
noting crackles,
wheezes,
rhonchi.
- Kept head of
bed elevated
- Encouraged
frequent
repositioning
and deepbreathing
exercises/coughi
ng as
appropriate
- Monitored vital
signs

- Investigated
changes in level
of
consciousness.

- Indicates
developing
complications
- Facilitates
breathing by
reducing pressure
on the diaphragm
-Aids in lung
expansion and
mobilizing
secretions

- Reveals changes
in respiratory
status, developing
pulmonary
complications.
-Changes in
mentation may
reflect hypoxemia
and respiratory
failure, which
often accompany
hepatic coma.

Within 30
minutes of
nursing
interventions,
the client has
established a
normal,
effective
respiratory
pattern as
evidenced by a
decrease in
respiratory rate
of 24 to 19

ASSESSMENT
S: Nag mamanas
po mga paa ko at
nag-simula lumaki
tyan ko apat na
buwan ng
nakakaraan, as
verbalized by the
client.
O:
- weak in
appearance
- abdominal
enlargement(abdom
inal girth of 95cm)
-decreased skin
turgor
-VS:
BP: 130-90
RR: 20
PR: 102
- urine specific
gravity: 1.020
- weight: 52 kg

BACKGROUND DIAGNOSI
S
Ascites is the
Fluid
term used to
volume
denote a fluid
deficit r/t
collection in the compromis
peritoneal
ed
cavity. Most
regulatory
commonly,
mechanism
ascites is due
secondary
to liver disease to
and the
impaired
inability of that liver
organ to
function as
produce
manifested
enough protein by weak in
to retain fluid in appearanc
the
e,
bloodstream.
decreased
Normally, water skin turgor,
is held in the
ascites and
bloodstream by bipedal
oncotic
edema
pressure. The
pull of proteins
keeps water
molecules from
leaking out of
the capillary

PLANNING

INTERVENTIONS

After 3 days
of nursing
interventio
ns, the
clients
fluid
volume will
improve as
evidenced
by reduced
signs of
edema and
decrease in
abdominal
girth

-Weigh daily or on
a regular
schedule, as
indicated
-Measure intake
and output
accurately

-Review lab data

(eg., BUN/Crea,
serum albumin,
proteins and
electrolyltes;urine
specific gravity)
-Discuss
importance of low
protein intake and
low salt intake
-Measure
abdominal girth
regularly
-Administer

RATIONALE

EVALUATI
ON
-Weight is the
After 3 days
most accurate of nursing
measure of
intervention
fluid status
s, the
- Reflects
patients
circulating
fluid
fluid volume
volume has
status,
improved
developing
within
fluid shifts,
clients
normal
limits, and
- To evaluate
a decrease
degree of fluid in
and electrolyte abdominal
imbalance and girth from
response to
99cm to
therapies
93cm
- Protein is
metabolized
into urea
- For changes
that may
indicate
increasing
fluid retention
in the 3rd

blood vessels
into
surrounding
tissues. As liver
disease
advances, its
ability to
manufacture

diuretics as
ordered

space -