Nursing Care Plan: Ineffective Tissue Perfusion (Hepatic) in Cirrhosis
Nursing Care Plan: Ineffective Tissue Perfusion (Hepatic) in Hepatic Cirrhosis
Nursing Assessment
Nursing Diagnosis
Goal
Nursing Intervention
Rationale
Evaluation
Subjective Data:
Reports fatigue, weakness, and dizziness
Complains of cold extremities
Expresses concern about frequent episodes of confusion
Feels "washed out" or unwell
Objective Data:
Pallor and cyanosis of extremities
Decreased skin turgor and cool, clammy skin
Weak peripheral pulses
Prolonged capillary refill time (>3 seconds)
Low blood pressure (hypotension)
Tachycardia
Changes in mental status (confusion, lethargy)
Reduced urine output
Signs of hepatic encephalopathy
Ineffective Tissue Perfusion (Hepatic) related to portal hypertension and decreased hepatic perfusion secondary to cirrhosis as manifested by pallor, cold extremities, weak pulses, altered mental status, and hypotension
Client will demonstrate improved tissue perfusion as evidenced by stable vital signs, warm extremities, normal capillary refill, increased urine output, and improved mental status.
Assess vital signs frequently, including BP, HR, RR, temperature, and oxygen saturation
Early detection of hemodynamic instability allows prompt intervention.
Client demonstrated improved tissue perfusion with stable vital signs, warm extremities, capillary refill within 2 seconds, and alert mentation.
Monitor skin color, temperature, and moisture
Indicates adequacy of peripheral perfusion and risk for hypothermia.
Assess capillary refill time and peripheral pulses
Prolonged refill and weak pulses suggest poor perfusion.
Monitor intake and output closely
Decreased urine output indicates renal hypoperfusion due to reduced cardiac output.
Assess level of consciousness and orientation
Altered mental status may indicate cerebral hypoperfusion or hepatic encephalopathy.
Administer fluids and medications as prescribed (e.g., albumin, vasopressors)
Supports intravascular volume and improves perfusion pressure.
Position patient in semi-Fowler’s or supine position to improve venous return
Enhances cardiac output and systemic perfusion.
Provide warmth with blankets and maintain room temperature
Prevents hypothermia and reduces metabolic demand.
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Nursing Care Plan: Activity Intolerance in Hepatic Cirrhosis
Nursing Care Plan: Activity Intolerance in Hepatic Cirrhosis
Nursing Assessment
Nursing Diagnosis
Goal
Nursing Intervention
Rationale
Evaluation
Subjective Data:
Reports feeling weak, fatigued, and unable to perform ADLs
Complains of malaise and inability to concentrate
Difficulty initiating movements
Feels dizzy or lightheaded on standing
Objective Data:
Pallor and jaundice
Diaphoresis
Weak appearance, limited range of motion
Respiratory rate increases with minimal activity
Heart rate elevates easily
Inability to complete self-care tasks independently
Activity intolerance related to generalized body weakness secondary to progressive disease state as manifested by pallor, body malaise, diaphoresis, inability to concentrate, and inability to perform ADLs, weak in appearance, limited ROM and difficulty initiating movements
Client will achieve maintenance of rest and comfort with improved energy conservation and ability to participate in activities of daily living.
Assess the degree of activity tolerance and degree of fatigue
Provides baseline data for better interventions.
After using above nursing interventions, the patient participated willingly in necessary activities, learned how to conserve energy, and verbalized relief from fatigue.
Provide adequate rest
Rest reduces metabolic demands on the liver.
Adjust the patient in a comfortable position in bed
Proper positioning helps in maximal respiratory efficiency and prevents bedsores.
Encourage patient to take high-protein and high-caloric diet frequently
Provides energy and helps in healing of tissues.
Administer Oxygen as ordered
Oxygenates damaged cells and prevents further damage.
Encourage the patient to exercise gradually and do self-care within limits
Regular exercise improves activity tolerance; promotes sense of control and accomplishment.
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Nursing Process for Fluid Volume Excess in Hepatic Cirrhosis
Nursing Care Plan for the Patient with Hepatic Cirrhosis – Fluid Volume Excess
Nursing Assessment
Nursing Diagnosis
Goal
Nursing Intervention
Rationale
Evaluation
Subjective Data:
Complaints of bloating and abdominal distension
Increased weight gain over days
Shortness of breath, especially when lying flat
Swelling in legs and feet
Feeling of fullness or pressure in the abdomen
Reduced urine output
Weakness and fatigue
Objective Data:
Pallor and jaundice
Abdominal distension with shifting dullness
Peripheral and dependent edema (ankles, sacrum)
Ascites confirmed by ultrasound
Increased blood pressure
Decreased serum albumin levels
Low urine output despite fluid intake
Positive jugular venous pressure (JVP)
Weight gain > 1 kg/day
Fluid volume excess related to compromised regulatory mechanisms secondary to cirrhosis of the liver as manifested by pallor, weakness, jaundice, abdominal distension, and edema
Client will maintain stable fluid balance with decreased edema and ascites, as evidenced by normal intake/output, stable weight, and improved respiratory status.
Assess hydration status regularly
Provides baseline data for fluid balance monitoring and early detection of worsening condition.
Client demonstrated stabilized fluid volume with maintained intake and output, reduced abdominal girth, and resolution of peripheral edema.
Assess respiratory status, noting increased respiratory rate or dyspnea
Indicates possible pulmonary congestion due to fluid overload, especially from ascites and pleural effusion.
Assess degree of peripheral and dependent edema
Fluid shifts into tissues result from sodium and water retention due to hypoalbuminemia and portal hypertension.
Monitor blood pressure
Elevated BP may indicate fluid volume overload; hypotension may suggest decompensation.
Monitor intake and output chart daily
Reflects circulating volume status and helps guide diuretic therapy.
Monitor serum albumin, electrolytes (especially potassium and sodium), and BUN/Cr
Decreased serum albumin reduces plasma colloid osmotic pressure, contributing to edema formation.
Encourage bed rest with leg elevation when ascites is present
Promotes recumbency-induced diuresis and helps mobilize edema and ascitic fluid.
Administer diuretics (e.g., spironolactone and furosemide) as prescribed
Reduces fluid overload by increasing urine output and decreasing sodium reabsorption.
Provide frequent mouth care and monitor for signs of dehydration
Decreases sensation of thirst and prevents dry mouth, especially when fluid intake is restricted.
Weigh patient daily at same time, using same scale and clothing
Daily weight is the most accurate indicator of fluid retention or loss.
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