Ineffective Tissue Perfusion - Heaptic 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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