Liver Cirrhosis Nursing Care Plan: 2 Sample Plans and Interventions

Cirrhosis is permanent scarring of the liver that blocks blood flow and stops the liver from doing its jobs. This causes fluid buildup in the belly (ascites), bleeding problems, and confusion from ammonia buildup. Your priorities are fluid balance, safety from bleeding and confusion, and teaching the client to avoid alcohol and liver-toxic drugs.

A · AssessmentD · DiagnosisP · PlanningI · InterventionE · Evaluation

Each care plan below follows the nursing process (ADPIE).

CARE PLAN 1 · NURSING DIAGNOSIS

Excess Fluid Volume

Related to

Low albumin and portal hypertension
Sodium and water retention

As evidenced by

Ascites with increasing abdominal girth
Weight gain
Peripheral edema
Shortness of breath from pressure on the diaphragm

PLANNING · EXPECTED OUTCOMES

Short-term goals

Abdominal girth and weight decrease daily as ordered
Client breathes comfortably with the head of bed raised

Long-term goals

Client follows a sodium-restricted diet and keeps a stable weight at home

ASSESSMENT

Daily weight and abdominal girth at the same spot each day
Strict intake and output
Respiratory effort and lung sounds
Sodium, potassium, albumin, and creatinine

INTERVENTIONS AND RATIONALES

INTERVENTION	RATIONALE
Give diuretics such as spironolactone and furosemide as ordered	They remove extra fluid, and spironolactone helps save potassium.
Restrict sodium, and fluids if ordered	Less sodium means less fluid retention.
Raise the head of the bed	This takes pressure off the diaphragm and eases breathing.
Assist with paracentesis and have the client void beforehand	Emptying the bladder lowers the risk of puncturing it during the procedure.
Give IV albumin as ordered	Albumin pulls fluid back into the blood vessels.

EVALUATION

Weight and girth are decreasing
Client breathes without distress
Client chooses low-sodium foods from a menu

CARE PLAN 2 · NURSING DIAGNOSIS

Acute Confusion

Related to

Rising ammonia levels from reduced liver function

As evidenced by

Disorientation and poor attention
Asterixis (flapping tremor of the hands)
Sleepiness or agitation
Elevated ammonia level

PLANNING · EXPECTED OUTCOMES

Short-term goals

Client is oriented to person and place within 48 hours of treatment
Client has 2 to 3 soft stools daily on lactulose

Long-term goals

Client stays free of falls and injury
Family can name early signs of confusion to report

ASSESSMENT

Mental status and level of consciousness every 4 hours
Presence of asterixis
Stool number and consistency
Ammonia and electrolytes

INTERVENTIONS AND RATIONALES

INTERVENTION	RATIONALE
Give lactulose as ordered and titrate to 2 to 3 soft stools a day	Lactulose traps ammonia in the gut and removes it in the stool.
Give rifaximin as ordered	It lowers the gut bacteria that make ammonia.
Use fall precautions and keep the bed low	A confused client is at high risk for falls.
Avoid sedatives and opioids when possible	The damaged liver cannot clear them, and they worsen confusion.
Monitor potassium closely	Low potassium from diarrhea or diuretics can raise ammonia.

EVALUATION

Client is oriented
Stool goal is met
Client remains free of falls

Practice this in Head-to-Toe

Practice finding ascites, jaundice, and asterixis during a full assessment.

Play Head-to-Toe

Quick answers

Why does a client with cirrhosis get lactulose?

To lower ammonia. Lactulose pulls ammonia into the bowel and removes it through soft stools, which improves confusion.

What bleeding risk is most dangerous in cirrhosis?

Ruptured esophageal varices. These swollen veins can bleed heavily and quickly, so report vomiting blood right away.

For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.