Assessment Subjective: N/A

Objective: Intake-1984.2 ml Output- 1940ml Difference- 44.2ml Bimanual and Bipedal edema Presence of crackles in both lungs fields upon auscultation Decrease haemoglobin-12. 1 Decrease haematocrit- 0.35 Radiology represents mild pulmonary congestion

Diagnosis Excess fluid volume related to impairment of renal system regulation

Inference Fluid shifting to intestinal tissues

Aldosterone secretion

H2O and Na retention

Planning Within 8 hours of nursing intervention, the patient will maintain normal fluid volume or balance as manifested by normal amount of Input and Output, absence of crackles and haemoglobin and haematocrit within normal range

Intervention Independent -Monitored vital signs and hemodynamic parameter every 2 hours especially BP and PR

Rationale

-for baseline data. Hypertension with increase heart rate will occur when kidneys failed to increase urine -Facilitate identification of fluid requirements based on renal function -Changes in Body weight help identifies fluid status -Adventitious breath sounds such as crackles will be heard in the development of pulmonary edema -Clinical evidence of edema is an indication of fluid shifting

Evaluate After 8 hours of nursing intervention, the patient had balance intake and out and stable vital signs and hemodynamic parameter

-Monitored I/O every shift

Edema -Weighed daily

-Auscultated lungs for adventitious breath sounds

-Observed for presence and characteristics of edema

-Monitored mental status

-indicate impending hypoxic state or acidosis or sepsis

Dependent -Administered fluid as per doctors order -Administered diuretics as per doctors order -Administered hypertensive as per doctors order

-to improve urine output -to improve urine output

-treat hypertension that occurs from decreased renal perfusion and fluid overload

Collaborative -Monitored ABGs

-for presence of acidosis