1

Subjective:
nde ko na
magalaw ng
maayos itong paa
ko simula nung
lumaki at tumaba
na ito, nakaka
ngalay as
verbalized by the
patient
Objective:
- +3 edema
on both foot
- +2 edema
on both
hands
- (+)
periorbital
edema
- (+)
proteinuria
- 30 ml urine
output for
the last 8
hours

Fluid volume
excess
related to
decreased
glomerular
filtration rate

Short term
goal:

Assessment:
1. Obtain complete
physical

Client will
have an
assessment.
increased
urine output of
2. Monitor daily
70-80 ml for
weight.
the next 6
hours.

1. To have baseline
data on the progress
of fluid elimination
through physical
appearance.
2. To have a
measurable account
on the fluid
elimination.

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
3. Monitor fluid intake 3. To know
day of nursing
and output every 4
progressing
intervention.
Long term
hours.
condition via
Patient also had an
goal:
glumerular filtration. average of 24 ml
of urine output for
Client will
4. Monitor BP and PR 4. To know
the last 10 hours.
have a
every
progression of
sustained
hypertension and
hour.
minimum
basis for further
urine output of
nursing intervention
20 ml per hour
or referral.
and manifest
5. Assess for
lesser edema
5. To know for
adventitious
breath
(+) 1.
possible progression
sounds.
in the lungs.
3

- Vital signs:
BP140/90
PR120 bpm

6. Monitor laboratory
values especially for
the protein level in the
urine.

6. To know the
extent of protein loss
which led to edema.

Treatment:
1. Maintain dietary
restrictions during

1.

acute phase.

a. to help prevent
fluid retention

a. sodium

via absorption.

b. protein

b. it helps prevent
fast elevation of
BUN level.

2. Maintain fluid
restriction

2. Helps prevent
further fluid
accumulation while
there is decreased
glumerular filtration.
3. Helps fluid

3. Elevate extremities
4

with pillows when at

rest or at lying
position.

excretion via gravity.

4. Administer diuretics 4. Helps excrete

excess fluids through
as ordered.
pharmacological
reaction.
5.Administer
antibiotics as ordered. 5. Fights infection
and progression of
scarring.
6. Administer anti
6. Controls
hypertensive drugs as
hypertension as
ordered.
caused by excessive
fluid.
Educative:
1. Encourage
ambulation and
non strenuous
exercises.
2. Teach on the
importance of
5

1. Helps increase
blood and fluid
circulation.

2. Reinforces
awareness on its
effect on fluid

elevating extremities
when at rest.

excretion.

clean and moist

skin.

3. Helps prevent skin

breakdown and
further infection
arising from the
skin.

4. Encouraged to stick
on dietary and fluid
restrictions.

4. For client
cooperation even in
the absence of any
medical practitioner.

3. Encouraged to
maintain