Nursing Care Plan
Client initials:
Assessment
Diagnosis
Excess fluid volume r/t
portal hypertension as
evidenced by increased
abdominal girth.
Age:
Diagnoses:
Plan
Goals/Outcomes
Goal: decrease excess fluid
volume
Interventions
Nursing Orders
Restrict sodium and fluid
intake as appropriate.
Rationale
Sodium restriction
minimizes fluid retention
in extravascular spaces.
Administer diuretics as
prescribed
Physicians may prescribe
medications such as
diuretics (e.g.,
Monitor daily weight for
spironolactone,
sudden increases using the furosemide) to control
same scale at the same time ascites and edema.
each day.
Albumin may also be given
as an adjunct to prevent
Provide a restricted sodium fluid re-accumulation.
diet as appropriate if
ordered.
Body weight is commonly
used to monitor fluid
Monitor for side effects of overload.
diuretic therapy.
Restricting sodium in the
diet will favor the renal
excretion of excess fluid.
Diuretics can cause
orthostatic hypotension,
hypovolemia, and
electrolyte imbalances.
Evaluation
Nursing Care Plan
Assessment
Diagnosis
Ineffective breathing
pattern related to
increased abdominal
girth as evidenced by
abnormal breathing
pattern
Plan
Goals/Outcomes
Interventions
Nursing Orders
Rationale
Evaluation