Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Evaluation

Subjective Cues: Excess fluid volume After 8 hours of nursing INDEPENDENT After 8 hours of nursing
related to intervention the patient interventions, the patient
compromised will display stable weight, was able to display
“NAMANAS YUNG regulatory vital signs within patients’ • Record accurate intake and • This is important for stable weight, vital signs
PAAS NYA” mechanism and normal range ang nearly output of the patient. determining renal function within patient’s normal
swollen feet, ankles, absence of edema. and fluid replacement. range, and nearly
verbalized by mother. legs, arms, and absence of edema.
hands as evidence
of edema. • Weight daily at same time of the • Daily body weight is to
Objective Cues: day on same scale with same monitor the fluid status.
equipment.
• EDEMA

• STOMACH • Assess skin, face dependent • Edema usually occurs in

INFLATION areas of edema. the dependent tissues of
our body. This will serve as
the parameter severity of
• WEIGHT GAIN fluid.
• V/S

T:36.2 • Monitor heart rate and blood • Tachycardia and

P:96 pressure. hypertension can occur
R:22 because of failure of the
kidneys to excrete urine.

• Assess skin, face, dependent • Edema occurs primarily in

areas of edema. dependent tissues of the
body. It will serve as
parameter the severity
of fluid excess.

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COLLABORATIVE
• Provide assessment of the
• Monitor laboratory and progression and
diagnostic study. management of the
dysfunction.