Nursing Diagnosis

Fluid volume excess

Possible Etiologies: decreased glomerular
filtration rate

Objectives
Short term goal:
Client will have an increased
urine output of 70-80 ml for
the next 6 hours.

Nursing Interventions
Assessment:
1. Obtain complete physical
assessment.
2. Monitor daily weight.

Disease Process: AGN

Long term goal:
Defining characteristics:
Subjective Data:
I felt mutated with this enlarged arms and
feet since if suffered from this illness, as
verbalized by the patient.
Objective Data:
+3 edema on both foot
+2 edema on both hands
(+) periorbital edema
(+) proteinuria
30 ml urine output for the last 8
hours
Vital signs:
BP140/90
PR120 bpm

Client will have a sustained

minimum urine output of 20 ml
per hour and manifest lesser
edema (+) 1.

3. Monitor fluid intake and

output every 4 hours.
4. Monitor BP and PR every
hour.

5. Assess for adventitious

breath sounds.
6. Monitor laboratory values
especially for the protein
level in the urine.
Treatment:
1. Maintain dietary
restrictions during
acute phase.
a. sodium

Rationale

1. To have baseline data on the

progress of fluid elimination
through physical appearance.
2. To have a measurable account
on the fluid elimination.
3. To know progressing
condition via glumerular
filtration.
4. To know progression of
hypertension and basis for
further nursing intervention or
referral.
5. To know for possible
progression in the lungs.
6. To know the extent of protein
loss which led to edema.

1.

a. to help prevent fluid retention

via absorption.
b. protein
2. Maintain fluid restriction

3. Elevate extremities with

pillows when at rest or at
lying position.
4. Administer diuretics as
ordered.
5.Administer antibiotics as
ordered.
6. Administer anti

b. it helps prevent fast elevation

of BUN level.
2. Helps prevent further fluid
accumulation while there is
decreased glumerular
filtration.
3. Helps fluid excretion via
gravity.
4. Helps excrete excess fluids
through pharmacological
reaction.
5. Fights infection and
progression of scarring.
6. Controls hypertension as

Evaluation
Client had a total urine output
of 72 ml 4 hours after the
implementation of the nursing
interventions.
Client had edema of (+) 1 the
second day of nursing
intervention. Patient also had
an average of 24 ml of urine
output for the last 10 hours.

hypertensive drugs as
ordered.
Educative:
1. Encourage ambulation and
non strenuous exercises.
2. Teach on the importance of
elevating extremities when
at rest.
3. Encouraged to maintain
clean and moist skin.
4. Encouraged to stick on
dietary and fluid
restrictions.

caused by excessive fluid.

1. Helps increase blood and fluid

circulation.
2. Reinforces awareness on its
effect on fluid excretion.
3. Helps prevent skin breakdown
and further infection arising
from the skin.
4. For client cooperation even in
the absence of any medical
practitioner.