Cues/evidences
Subjective Data:
“She seemed to be a bit
confused in her responses to
everyday situation and has
difficulty sleeping,” as
reported by her son
Objective Data;
Bipedal Edema 2+
Crackles at the base of the
lungs
GCS: E- 4; V- 4; M- 6 14/15
Vital Signs:
BP: 110/ 70
T: 36.8 degrees
Centigrade
PR: 89 BPM (slight
tachycardia)
RR: 25 BPM
Weight: 76 kg (slight
weight gain)
Nursing Diagnosis Objectives/Planning
Excess Fluid volume Short-Term Goal:
related to decreased After 2 hours of nursing
cardiac output as intervention the patient will
evidenced by slight weight verbalize understanding of
gain, edema, abnormal causative factors and
breath sounds, changes in demonstrate behaviors to
mental status and resolve excess fluid volume.
restlessness
Long-Term Goal:
After 5 days of nursing
intervention the patient will
demonstrate adequate fluid
balanced as evidenced by
output equal to exceeding
intake, clearing breath sounds,
and decreasing edema.
Nursing Interventions
Independent:
Establish rapport
Monitor and record VS
Assess patient’s general condition
Monitor I&O every 4 hours
Weigh patient daily and compare to previous
weights.
Follow low-sodium diet and/or fluid restriction
and Encourage or provide oral care q2
Obtain patient history to ascertain the
probable cause of the fluid disturbance.
Monitor for distended neck veins and ascites
Change position frequently. Elevate feet
when sitting. Inspect skin surface, keep dry,
and provide padding as indicated.
Collaborative:
Administer medication as ordered
Furosemide (Lasix) 40 mgIV every 8 hours
KCl 40mEq IV (incorporated to 1 L of
PNSS) run for 24 hours
Consult with dietitian.
Rationale
To gain patient’s trust and
cooperation
To obtain baseline data
To determine what approach to use
in treatment
I&O balance reflects fluid status
Body weight is a sensitive indicator
of fluid balance and an increase
indicates fluid volume excess.
The client senses thirst because the
body senses dehydration. Oral care
can alleviate the sensation without
an increase in fluid intake.
May include increased fluids or
sodium intake, or compromised
regulatory mechanisms.
Indicates fluid overload
Edema formation, slowed
circulation, altered nutritional intake,
and prolonged immobility (including
bed rest) are cumulative stressors
that affect skin integrity and require
close supervision/ preventive
interventions.
Increases rate of urine flow and
may inhibit reabsorption of sodium/
chloride in the renal tubules.
Replaces potassium that is lost as a
common side effect of diuretic
therapy
May be necessary to provide diet
acceptable to patient that meets
caloric needs within sodium
restriction.
Cues/evidences Nursing Diagnosis Objectives/Planning Nursing Rationale
Interventions
Subjective Data: Activity intolerance related Short-Term Goal: Independent:
“Mabilis tsaka madalas na to imbalance O2 supply After 1 hour of nursing Establish Rapport To gain clients participation and
akong mahapo kahit konti and demand as evidenced intervention the patient will use cooperation in the nurse patient
lang ung ginagawa ko,” as by client reports of identified techniques to interaction
verbalized by the client weakness and abnormal improve activity intolerance Monitor and record Vital Signs To obtain baseline data
pulse rate and rhythm Assess patient’s general condition To note for any abnormalities and
Objective Data: Long-Term Goal: deformities present within the body
BP: 110/ 70 After 5 days of nursing Adjust client’s daily activities and reduce To prevent strain and overexertion
T: 36.8 degrees intervention the patient will intensity of level. Discontinue activities that
Centigrade report measurable increase in cause undesired psychological changes
PR: 89 BPM (slight activity as evidenced by Instruct client in unfamiliar activities and in To conserve energy and promote
tachycardia) reduced fatigue and weakness alternate ways of conserve energy safety
RR: 25 BPM and by vital signs within Encourage patient to have adequate bed rest to relax the body
acceptable limits during and sleep
activity. Provide the patient with a calm and quiet To provide relaxation
environment
Assist the client in ambulation To prevent risk for falls that could
lead to injury
Note presence of factors that could Fatigue affects both the client’s
contribute to fatigue actual and perceived ability to
participate in activities
Give client information that provides To sustain motivation of client
evidence of daily or weekly progress
Assist the client in a semi-fowlers position To promote easy breathing
Elevate the head of the bed To maintain an open airway
Assist the client in learning and
demonstrating appropriate safety measures To prevent injuries
Instruct the SO not to leave the client To avoid risk for falls
unattended
Provide client with a positive atmosphere To help minimize frustration and
rechannel energy
Instruct the SO to monitor response of To indicate need to alter activity
patient to an activity and recognize the signs level
and symptoms