ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONAL EVALUATION

E
SUBJECTIVE: fluid volume Goal:  Monitor vital signs  Use as a Goals Partially
“I feel like my whole body is excess related to The patients frequently. baseline data. met.
swelling. I cannot urinate, decrease urine will be able to  Assess fluid status and  To identify
and I feel so weak”. As output and maintain his identify potential potential source  Patient
verbalize by the patient. retention of ideal body sources of imbalance of fluid stated
sodium and water weight  Space fluids, allowing imbalance. normal urine
OBJECTIVE: without 400 mL from 0700 to  To balance the output (more
 R leg edema (0-1) excess fluid 1500, 200 mL from fluid in the than 400)
 increase blood 1500 to 2300, and 100 body.  BP decreased
pressure (180/100 Objectives: mL from 2300 to 0700. from
mmHg) After 8 hours  Provide mouth care at 180/100 to
 decrease urine of nursing least every 4 hours 130/90
output (less than interventions and before every  Ideal body
400) the patient meal. weight is
 increase urea and will able to:  Keep sugarless hard  To prevent maintained
creatinine level in candy and ice chips at excessive fluid.  Decreased
blood • Adhere to the the bedside; include occurrence
Findings Normal prescribed ice consumed as fluid of edema at
Values fluid intake. right leg.
creatinine 205 53 - 97 restriction of  Weigh daily before
BUN 23 7-21 750 mL per breakfast; monitor
mg/dL day. vital signs, and heart
• Demonstrate and lung sounds  Use as a
reduced every 4 hours. baseline data.
extracellular  Document intake and
fluid volume output every 4 hours.
by weight loss,  Arrange dietary
decreased consultation for
peripheral menu planning.
edema, clear  Monitor food intake,
lung sounds, noting percentage
 and normal and types of food
heart sounds. consumed.
• Consume and  Assist to identify
retain 100% of strengths and needs
prescribed in health regimen
diet, including management.
snacks.  Monitor patient’s
• Exhibit normal progress and
skin turgor compliance with
• Remain free of treatment regimen.
infection.