NURSING CARE PLAN

CUES NSG DIAGNOSIS BACKGROUND KNOWLEDGE

PLANNING INTERVENTION RATIONALE EVALUATION

Objective: Edema Hypertension Weight gain Pulmonary

congestion (SOB, DOB)

Oliguria Distended

jugular vein Changes in

mental status

Fluid Volume Excess R/T decrease Glomerular filtration Rate and sodium retention

Renal disorder impairs glomerular filtration that resulted to fluid overload. With fluid volume excess, hydrostatic pressure is higher than the usual pushing excess fluids into the interstitial spaces. Since fluids are not reabsorbed at the venous end, fluid volume overloads the lymph system and stays in the interstitial spaces leading the patient to have edema, weight gain, pulmonary congestion and HPN at the same time due to decrease GFR,

Short Term:After 4-8 hours of nursing interventions, patient will demonstrate behaviors to monitor fluid status and reduce recurrence of fluid excess

Long Term:After 3 days of nursing intervention the patient will manifest stabilize fluid volume AEB balance I & O, normal VS, stable weight, and free from

1. Establish rapport

2. Monitor and record vital signs

3. Assess possible risk factors

4. Monitor and record vital signs.

5. Assess patient’s appetite

6. Note amount/rate of fluid intake from all sources

7. Compare current weight gain with admission or previous stated weight

8. Auscultate breath sounds

1. To assess precipitating and causative factors.

2. To obtain baseline data

3. To obtain baseline data

4. To note for presence of nausea and vomiting

5. To prevent fluid overload and monitor intake and output

6. To monitor fluid retention and evaluate degree of excess

7. For presence of crackles or congestion

8. To evaluate

Short Term:The patient shall have demonstrated behaviors to monitor fluid status and reduce recurrence of fluid excess

Long Term:The patient shall have manifested stabilized fluid volume AEB balance I & O, normal VS, stable weight, and free from signs

Name: Chief Complain:Age: Diagnosis:Room No.: Attending Physician:

nephron hyperthrophized leading to decrease ability of the kidney to concentrate urine and impaired excretion of fluid thus leading to oliguria/anuria.

9. Record occurrence of dyspnea

10. Note presence of edema.

11. Measure abdominal girth for changes.

12. Evaluate mentation for confusion and personality changes.

13. Observe skin mucous membrane.

14. Change position of client timely.

15. Review lab data like BUN, Creatinine, Serum electrolyte.

16. Restrict sodium and fluid intake if indicated.

Dependent:1. Give medications as ordered.

degree of excess

9. To determine fluid retention

10. May indicate increase in fluid retention

11. May indicate cerebral edema.

12. To evaluate degree of fluid excess.

13. To prevent pressure ulcers.

14. To monitor fluid and electrolyte imbalances

15. To lessen fluid retention and overload.

16. To monitor kidney function and fluid retention.

1. To aid in patient’s recovery.

TEODORO, MICHELLE ANN T. BSN 4