S “Madalang lang umihi yung anak ko at napansin ko na namamaga ang kanyang mukha at mga paa.

”
verbalized by the mother of the patient.

O - Presence of edema (periorbital ) , over the face and lower extremities

- (+) proteinuria
- Depressed C3 level 0638 g/L
- hypoalbuminemia of 2.0 g/dL
- -urine creatinine level of 620 mg/L
- - APTT was prolonged- 47.7 sec

A Excessive fluid volume related to fluid accumulation as evidenced by pitting edema to face in lower limbs and
decreased urine output.
P Short Term Goal:
After 8 hours of nursing interventions the patient will stabilize fluid volume as evidence by: balanced I/O

Long Term Goal:

After 3 days of nursing interventions the patient will manifest stabilize fluid volume, balance I&O, stable
weight and free from signs of edema.

I Independent:
 Record accurate fluid intake and output of the patient
 Weigh daily at same time of the day, on same scale, with same equipment and clothing.
 Assess patient’s appetite
 Assess neuromuscular reflexes
 Assess skin, face, dependent areas of edema.
 Assess level of consciousness presence of restlessness
Dependent:

 Restrict fluid and sodium intake as indicated

 Administer, prednisone, human albumin, furosemide, ceftriaxone

Collaborative:
  Collaborate to dietician as needed

E Short Term Goal:

After 8 hours of nursing interventions the patient will stabilized fluid volume as evidenced by: balanced I/O

Long Term Goal:

After 3 days of nursing interventions the patient will manifest stabilized fluid volume, balance I&O, stable
weight and already free from signs of edema.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Excessive fluid Short Term Independent: Short Term
“Madalang lang umihi volume related Goal: 1. Record 1. Accurate Goal:
yung anak ko at napansin to fluid accurate fluid intake and
ko na namamaga ang accumulation as After 8 hours of intake and output is After 8 hours of
kanyang mukha at mga evidenced by nursing output of the nursing
necessary for
paa.” verbalized by the pitting edema to interventions patient interventions the
the patient will determining patient will
mother of the patient. face in lower
limbs and stabilize fluid 2. Weigh daily at renal function stabilized fluid
Objective: decreased urine volume as same time of and fluid volume as
- Presence of output. evidence by: the day, on replacement evidenced by:
edema balanced I/O same scale, needs and balanced I/O
(periorbital ) , with same reducing risk
over the face Long Term equipment and Long Term
Goal: of fluid Goal:
and lower clothing.
extremities overload.
- (+) proteinuria After 3 days of 3. Assess 2. Daily body After 3 days of
- Depressed C3 nursing patient’s weight is the nursing
level 0638 g/L interventions appetite best monitor interventions the
the patient will of fluid status patient will
- hypoalbuminemi
manifest 4. Assess 3. To provide manifest
a of 2.0 g/dL
stabilize fluid neuromuscular further stabilized fluid
- -urine creatinine
volume, balance reflexes intervention volume, balance
level of 620 mg/L
I&O, stable 4. To determine I&O, stable
- - APTT was 5. Assess skin,
weight and free if the patient weight and
prolonged- 47.7 is confused
from signs of face, already free from
sec and changes
edema. dependent signs of edema.
areas of in his
personality.
edema.
5. Edema
occurs
6. Assess level
primarily in
 of dependent
consciousness tissues of the
presence of body. It will
restlessness serve as
parameter the
Dependent: severity of
fluid excess.
7. Restrict fluid 6. May reflect
and sodium fluid shifts
intake as and
indicated electrolyte
imbalances.
8. Administer, 7. To prevent
prednisone, worsening of
human patient’s
condition.
albumin,
8. To address
furosemide, the patient's
ceftriaxone condition and
avoid certain
Collaborative: complications
9. To provide
appropriate
9. Collaborate to nutrition
dietician as based in the
needed patient’s
condition