ACTUAL NURSING CARE PLAN

ASSESSMENT OBJECTIVES NURSING RATIONALE EVALUATION Explanation of the

INTERVENTIONS Problem
Fluid Volume Excess
S>”medyo tumabtaba Short Term: > Serve as a baseline data Short Term: Fully met (FVE), or hypervolemia,
dytoy sakak kasla ag > Monitored vital signs and refers to an isotonic
pumtok” After 4-8 hours of nursing record accordingly. After 4-8 hours of nursing expansion of the
interventions, patient will: > To reduce tissue pressure interventions, patient: extracellular fluid (ECF)
O> vital signs taken as >Elevate edematous and of skin breakdown due to an increase in total
follows: 1. Demonstrate extremities, change Demonstrated body sodium content and
-BP=140/80mmHg behaviors to position frequently >To prevent fluid overload behaviors to total body water. This fluid
-RR=20cpm monitor fluid status and monitor intake and monitor fluid status overload usually occurs
-PR=61bpm and reduce >Assessed px appetite output and reduce from compromised
-T=36.5oC recurrence of fluid recurrence of fluid regulatory mechanisms for
➢ conversant and excess excess sodium and water as seen
cooperative >Established rapport. >To assess precipitating commonly in heart failure,
➢ Presence of edema 2. Verbalize and causative factors Verbalized kidney failure, and liver
on foot understanding of >Compare current weight understanding of failure. Other medical
➢ Shortness of breath individual dietary gain with admission or >For presence of crackles individual dietary conditions that could
➢ Jugular vein and fluid previous stated weight or congestion and fluid contribute to FVE are
distention restrictions restrictions hemodialysis, peritoneal
➢ Weight gain >Record occurrence of >To determine full dialysis, and myocardial
Long Term: After 3 days of dyspnea retention infarction. Ultrafiltration or
nursing intervention the Long Term: Fully met dialysis may be required
patient will manifest >Note presence of edema >May indicate increase in for acute cases.
stabilize fluid volume AEB fluid intake After 3 days of nursing
balance I & 0, normal VS, >Record IandO accurately intervention the patient
Nursing diagnosis: stable weight and free from and calculate fluid volume >accurate intake and output manifested to stabilize fluid
Excess fluid volume related signs of edema. balance are necessary for volume AEB balance I & 0,
to excessive fluid intake determining renal function normal VS, stable weight
secondary to kidney failure >Administer diuretics as and fluid replacement and free from signs of
ordered needs and reducing risk of edema.
fluid overload
>Weight patient daily at the
same time each day >To excrete excess fluid

>Daily body weight is best

to monitor fluid status