Assessment

SUBJECTIVE: “Napansin ko na lumalaki ang tiyan ko”
(I feel that my tummy is etting bigger) as verbalized by

Nursing Diagnosis
Fluid volume excess related to compromised Regulatory mechanism.

Planning
 After 8 hours of nursing interventions, the patient will demonstrate stabilized fluid volume and decreased edema.

Intervention
INDEPENDENT:  Measure intake and output, weigh daily, and note weight gain more than 0.5 kg/day.  Assess respiratory status, noting increased respiratory rate, dyspnea.  Monitor blood pressure.  Auscultate lungs, noting diminished/absent breath sounds and developing adventitious sounds.  Assess degree of peripheral/dependent edema.  Measure abdominal girth.

Rationale
 Reflects circulating volume status. Positive balance/weight gain often reflects continuing fluid retention.  Indicative of pulmonary congestion.  Blood pressure elevation usually associated with fluid volume excess but may not occur because of fluid shifts out of the vascular space.  Increasing pulmonary congestion may result in consolidation, impaired gas exchange, and complications. •

Evaluation
After 8 hours of nursing interventions, the patient was able to demonstrate stabilized fluid volume and decreased edema.

the patient. OBJECTIVE:      Anasarca Weight gain Altered Electrolyte levels V/S taken as follows: T: 37.4 PR. 88 RR. 22 BP. 100/60

 Encourage bed rest when ascites is present. COLABORATIVE:  Administer medications as indicated. Such as diuretics.  Monitor electrolytes.

 Fluid shift into tissues as a result of sodium and water retention, decreased albumin, and increased anti diuretic hormone (ADH).  Reflects accumulation of fluid (ascites) resulting from loss of plasma proteins or fluid into peritoneal space.  May promote ecumbencyinduced diuresis.  To control edema and ascites.  To correct further imbalances.

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