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NURSING DIAGNOSIS NURSING GOAL NURSING NURSING EVALUATION

INTERVENTIONS
01 November 2021 1. Establish rapport

Fluid volume excess
related to compromised
regulatory mechanism
Objective:
After 12 hours of nursing
intervention, the patient will
stabilizefluid volume as
evidenced by:
2. Monitor and record vital After 12 hours of nursing
signs intervention, the patient
have stabilizedfluid volume
3. Assess possible risk as evidenced by:
factors

 (+)Pitting Edema in  Absence of Lower 4. Note amount/rate of fluid  Decreased Lower

Lower Extremities Extremity Edema intake from all sources Extremity Edema
grade 2 Grade 1, 2mm
5. Compare current weight
 Balance Intake & depression
 Oliguria gain with admission or
Output previous stated weight
 Alteration in Vital  Balance Intake and
Signs  Normal Vital Signs 6. Auscultate breath Output
sounds
 Normal Vital Signs
7. Record occurrence of
dyspnea GOAL PARTIALLY MET
8. Note presence of
edema.

9. Measure abdominal girth

for changes.

10. Evaluate mentation for

confusion and
personality changes.
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11. Observe skin mucous

membrane.

12. Change position of client

timely.

13. Review lab data like

BUN, Creatinine, Serum
electrolyte.

14. Restrict sodium and fluid

intake if indicated

15. Record I&O accurately

and calculate fluid
volume balance

16. Weigh client

17. Encourage quiet, restful

atmosphere.

NURSING DIAGNOSIS NURSING GOAL NURSING NURSING EVALUATION

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INTERVENTIONS
01 November 2021
1. Assess patient’s
Risk for Decreased After 12 hours of nursing After 12 hours of nursing
condition
cardiac output r/t altered interventions the patient will interventions the patient
afterload (e.g., systemic be able to display 2. Monitor and record vital have displayed
vascular resistance) hemodynamic stability as hemodynamic stability as
evidenced by: signs evidenced by:
3. Encourage patient to
Subjective Cues:
verbalize concerns
“ Nanghihina pa rin ako” as
verbalized by the patient. 4. Administer oxygen via
face mask or nasal

Objective Cues: cannula

The patient manifested: 5. Assist with or perform

 (+)Pallor  Absence of Pallor self-care activities for  Pallor
 Capillary refill of 2-3  Blood pressure within client  Blood pressure within
normal range normal range
sec 6. Encourage patient to
 Skin is warm to touch  Skin is warm to touch
 Alteration in Blood change position every  Balance intake and
Pressure  Balance intake and two hours output
output
 Cold clammy skin 7. Encourage patient to do GOAL PARTIALLY MET
 Oliguria relaxation techniques

8. Encourage patient to
engage in divertional
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activities

9. Provide adequate rest

10. Reinforced low salt and

low fat diet

11. Review laboratory and

diagnostic data

12. Evaluate client reports

and evidence of fatigue
intolerance for activity,
sudden or progressive
weight gain, telling of
extremities and shortness
of breath

13. Administer medications

as appropriate and
monitor cardiac
responses
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NURSING DIAGNOSIS
01 November 2021
Ineffective peripheral
tissue perfusion related to
Diabetes Mellitus and
Hypertension
Objective Cues:
Fatigue
(+)Pallor
Oliguria
Decreased Peripheral
Pulses
Alteration in skin
characteristics
Grade 1 Edema on Lower
Extremities
NURSING GOAL
After 12 hours of nursing
interventions, the patient will
be able to demonstrate
adequate tissue perfusion
as evidenced by :
 Decrease feeling of
Fatigue
 Absence of Pallor
 adequate urinary
output
 palpable peripheral
pulses
 Skin is warm to touch
 Absence of Edema
NURSING NURSING EVALUATION
INTERVENTIONS
1. Assessed patient’s
condition.
After 1- 2 days of nursing
2. Monitored and interventions, the patient
have demonstrated
recorded vital signs.
adequate tissue perfusion
3. Noted color and as evidenced by :
temperature of the
skin.  Decrease feeling of
4. Monitored peripheral Fatigue
 (+)Pallor
pulse.
 adequate urinary
5. Measure Capillary output
Refill  palpable peripheral
pulses
6. Current situation or
 Skin is warm to touch
presence of
 Grade 1 Edema on
conditions Lower Extremities
7. Review Laboratory
studies
8. Provided a warmth GOAL PARTIALLY MET
environment.
9. Monitored urine
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output.
10. Administer
medications as
ordered such as
antiplatelet agents,
thrombolytics, and/or
antibiotics as
ordered.