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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