Bulacan State University

COLLEGE OF NURSING
City of Malolos, Bulacan

INDIVIDUAL NURSING CARE PLAN

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”

Clinical Area:

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

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