4.

Assess for presence of

edema by palpating over
tibia, ankles, feet, and
sacrum. Evaluate
edematous extremities,
change position
frequently.
® To know the extent of
fluid accumulation in the
area involved and to
reduce tissue pressure
and risk of skin
breakdown if edema is
noted;
5. Monitor patient’s vital
signs
® to evaluate degree of
excess

6. Auscultate breath

123
 sounds for presence of
crackles and congestion.
® To evaluate the degree
of fluid volume excess.
7. Monitor I &O closely
® Provides ongoing
estimate of volume
replacement needs,
kidney function, and
effectiveness of therapy.

8. Maintain limitation of
fluid intake to the
prescribed volume
1000cc/ day.
® Fluid restriction will
determine on basis of
response to therapy.
Maintains hydration

9. Suggest interventions,

124
 such as frequent oral
care.
® to reduce discomforts
of fluid restrictions

10. Explain to the patient

and family the reason for
fluid restriction.
® Understanding
promotes cooperation.

125