Patient’s Initial: L.M. Age: Gender: Female Date Handled: Medical Diagnosis: Chief Complaint “Namamaga ang mga binti at paa ko” as verbalized by the patient”
Subjective: Fluid Volume Excess Short term goal: Independent: - To assess precipitating Short term evaluation: “Namamaga ang related to sodium After 8hours of nursing - Establish rapport & causative factors After 8 hours of nursing retention as manifested intervention patient will - Monitor and record vital - To obtain baseline intervention, patient mga binti at paa ko” By presence of edema in verbalized signs. data. verbalized as verbalized by the both lower extremities understanding of the - Compare current weight gain - To obtain baseline understanding of patient” measures to prevent and with admission or previous data. measures to prevent and lessen fluid volume stated weight. lessen fluid volume excess - Discuss the following excess. measures to prevent and lessen Objective: fluid volume excess. Presence of edema in both Dependent: lower A.) Advise patient to elevate - This prevent and extremities. feet when sitting down. lessen fluid Long term evaluation: Long term goal: accumulation is lower B.) Instruct the patient extremities regarding restricting - Intake of fluid up to fluid intake. 500ml is equivalent to 0.5kg. Increase in Vital Signs: Interdependent/Collaborative: weight due to fluid BP- 110/90 retention. Therefore PR- 90bpm limiting is necessary to RR- 24 avoid fluid retention. T- 36.3’C