Fluid Volume Excess- 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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