Assessment Diagnosis Planning Implementation Rationale Evaluation

Objective : Excess fluid Short term Goal : Dependent : GOAL MET

Edema on volume After 2 Days of Short term : - Potent loop diuretic; Short term Goal :
both arms related to rendering nursing -Administer Diuretic as inhibits sodium and chloride After 2 hours of
and legs decrease intervention the prescribe. (e.g ethacrynate reabsorption at the proximal rendering nursing
cardiac client will : sodium) and distal tubules and the intervention the
BP : 160/110 functioning as ascending loop of Henle client had :
mmHg evidence by -Control fluid
Edema, BP of volume as evidence - Administer -Stabilize fluid
PR : 106 Bpm 160/110 by balanced input Antihypertensive drugs as A direct-acting peripheral volume as
mmHg, PR of and output, prescribe (e.g hydralazine vasodilator that relaxes evidence by
106 bpm hydrocloride) arteriolar smooth muscle balanced input
- Control vital signs and output, Vital
within client normal -Set an appropriate rate of signs within client
limits. fluid intake/infusion normal limits.
throughout 24 hour period - to prevent peaks/valleys in
- Demonstrate as indicated fluid level and thirst - Demonstrate
behaviors to behaviors to
monitor fluid status monitor fluid
and reduce Independent : status and reduce
recurrence of fluid Short term : recurrence of fluid
access -Elevate edematous - reduce tissue pressure and access
extremities change position risk of skin breakdown GOAL MET
Long term Goal: frequently Long term Goal:
After 1 week of After 1 week of
rendering nursing -Record Input and output - so that adjustment can be rendering nursing
intervention the accurately ; calculate 24- made in following 24-hr intervention the
client will : hour fluid balance intake if needed client had :

- Stabilize fluid - Stabilize fluid

volume as evidence - Monitor Vital signs
by stable weight
and free signs of Long term :
edema - Discuss fluid restrictions
and “hidden source” of fluids
- Verbalize (e.g food high on water
understanding of content such as fruits, ice
individual dietary cream, sauces or custard)
and fluid restriction
-Discuss about food intake
and Avoid salty or spicy
foods
volume as
evidence by stable
weight and free
- as they increase thirst or signs of edema
fluid retention
- Verbalize
understanding of
individual dietary
- This provides a comparative and fluid
baseline and evaluates restriction
effectiveness of diuretic
therapy when used.

- Weigh daily or an regular

schedule, as indicated
compare current weight with
previously stated weight

Collaborative :
Short term :
Refer to Dietitian - To develop dietary plan and
identify foods to be limited
or omitted