ASSESSMENT DIAGNOSIS Inference GOAL IMPLEMENTATION RATIONALE EVALUATION

Subjective: “May Fluid Renal After 8 hours Independent Goal was partially
maga yung mata Volume failure of Nursing -Record accurate -Accurate I&O is met as the patient’s
ko tsaka minsan Excess r/t Intervention, Input and Output necessary for peripheral edema
kasama mukha Compromis Decreased the patient determining renal was lessen.
pati yung mga paa ed blood will be able to function
ko namamanas.” regulatory flow to display
As verbalized by mechanism kidneys appropriate -Assess skin, face -Edema occurs
the patient. (CKD) urinary output and areas possible primarily in dependent
Decreased with GFR for edema. tissues of the body
objective data: -- perfusion near normal;
--Palpebral edema in kidneys vital signs -Inspect skin for -Detects presence of
--Face Swelling within changes in color, dehydration or
--Edema on lower Decreased patient’s turgor, vascularity overhydration that
extremities Urinary normal range; affect circulation and
--Weakness and output and absence tissue integrity at the
Malaise of edema. cellular level.-
--Dryness of Skin indicates areas of poor
--<15 GFR (Stage Water circulation/breakdown
5 CKD) Retention that may lead to
infection.

Urinary output: Fluid

17cc per hour Volume - Suggest loose -Prevents direct
excess fitting cotton dermal irritation and
VS taken as garments to wear. promotes evaporation
follows: of moisture on the skin

BP: 140/90
mmHg
PR: 97 bpm Collaborative
RR: 23 cpm -Administer/restrict -Fluid management is
Temp: 36.7 C fluids as indicated usually calculated to
 replace output from all
sources.

-May act as
counteracting effect of
-Administer decreased renal blood
Antihypertensive flow and/or circulating
meds as prescribed volume overload