ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Fluid volume excess r/t
“parang bumibigat and paa decrease glomerular
ko” verbalized by pt. filtration rate and sodium
retention
Objective:
Peripheral edema Interference:
Hypertension (Renal disorder impaired
BP 130/100 mmHg glomerular filtration that
Weight gain resulted to fluid overload.
67kg – 78kg Which pushes into interstitial
spaces that cause edema and
gain weight.)
Short term:
After 4 hours of NI, patient
will demonstrate behavior of
self-monitoring fluid status
and reduce occurrence of
fluid excess
Long term:
After 2 days of NI, patient will
manifest stabilize fluid
volume, normal weight, free
from signs of edema.
-Established rapport
-Monitored and recorded VS
-Noted amount of fluid intake -To monitor fluid retention
from all sources.
-Compared current weight
gain with admission or
previous stated weight.
-Assessed for possible risk
factors
-To assess participating and
gain trust.
-To obtain baseline data.
and evaluate degree of
excess.
-For possible presence of
congestion.
-To note for nausea and
vomiting
Short term:
After 4 hour of NI, patient
had demonstrated behavior
of self-monitoring fluid status
and reducing occurrence of
fluid excess.
Long term:
After 2 days of NI, patient
had manifested stabilize fluid
volume, normal weight, and
free from signs of edema.

-Assessed patient diet -To prevent overload and

monitor intake and output

-Restricted from sodium and -Sodium attacks water

minimized fluid intake.