Date Cues Needs Nursing Diagnosis Planning Nursing Intervention Evaluation

Sept. 9, Subjective: N Fluid volume excess After eight hours of 1. Assess skin, face, and dependent GOAL
2010 “Hubag lagi akong U related to compromised nursing care, the areas for edema. PARTIALLY MET.
@ 7-3 tiil day maong T regulatory mechanism patient will be able Rationale: Edema occurs primarily in Patient was able to:
shift nabalaka jud ko,” as R (renal failure) as
to: dependent tissues of the body. Display appropriate
verbalized by the I evidenced by 1. Display urinary output,
patient. T generalized tissue appropriate 2. Monitor heart rate, blood pressure, achieved stable
I edema and weight gain. urinary output JVD/CVP. weight and follow
O 2. Achieve the prescribed
Objective: N stable weight; 3. Auscultate lung and heart sounds. pharmacologic
 Distended A 3. Demonstrate Rationale: Fluid overload may lead to treatment however
jugular vein L absence of pulmonary edema and heart failure edema is still
 Edema; edema. evidenced by development of present.
pitting M 4. Follow the adventitious breath sounds and extra
Scientific Basis:
 Weight gain; E prescribed heart sounds.
Fluid volume excess
from 70 kg to T pharmacologi
refers to an isotonic
80 kg. A c treatment. 4. Asses level of consciousness;
expansion of the ECF
 BP: 180/100 B investigate changes in mentation,
caused by the abnormal
O presence of restlessness.
retention of water and
L Rationale: May reflect fluid shifts,
sodium in
I accumulation of toxins, acidosis,
approximately the same
C electrolyte imbalances or developing
proportions in which
hypoxia.
they normally exist in
P
the ECF.
A 5. Record accurate intake and output.
T Rationale: To determine renal
T function and fluid replacement needs
E and reduce risk of fluid overload.
R
N 6. Weigh daily at same time of day, on
same scale, with same equipment and
clothing.
Rationale: Daily body weight is the
best monitor of fluid status.

7. Monitor laboratory/diagnostic
studies.
Rationale: Assess progression and
management of renal
dysfunction/failure.

8. Plan oral fluid replacement with

patient within multiple restrictions.
Interspersed desired beverages
throughout the shift and vary
offerings.
Rationale: Helps avoids periods
without fluids, minimizes boredom of
limited choices, and reduces sense of
deprivation and thirst.

9. Monitor laboratory/diagnostic
studies.
Rationale: Assess progression and
management of renal
dysfunction/failure.

10. Administer/restrict fluids as

indicated.
Rationale: Fluid replacement is
usually calculated to replace output
from all sources plus estimated
insensible losses.