NURSING CARE PLAN 1

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Excess fluid Within 4 hours of INDEPENDENT INDEPENDENT After 4 hours of

“Namamaga po volume as nursing nursing
yung dalawang manifested by interventions the  Monitor and note BP and HR  Sinus Tachycardia and increase BP are evident interventions the
paa ko,” as grade 2 bipedal patient will be in early stage patient would
verbalized by the edema able to Decrease  Monitor input and output Closely  To determine changes in the hydration status of Decrease the
client. the appearance of the patient appearance of
edema from +3 to  Educate patient to limit food that high in  Restriction in Sodium aids in decreasing Fluid edema from +3 to
+1 sodium retention +1 GOAL WAS
Objective data:  Elevated edematous extremities and  Elevation increases venous return to the heart MET
handle with care and, in turn, decreases edema. Edematous skin
is more susceptible to injury
 Bilateral  Repositioning prevents fluid accumulation in
 Repositioning patient every 2 hours
edema in dependent areas and promote movement of
lower fluids
extremities
 Pitting edema DEPENDENT
DEPENDENT
+3
 Administer Diuretics medication as  Diuretics aids in the excretion of excess body
prescribed by the physician fluid

 Administer IV fluids in through infusion  Pumps guarantee precise delivery of IV fluids

pump, if possible

COLLABORATIVE COLLABORATIVE

 Cooperate with the dietitian or  To identify exact food to our patient

nutritionist for appropriate meal for the which correlated to its condition
patient
Patient Education
Medication
-Take all of your prescribed medications every day. Your heart failure medication plan is designed to keep your heart as healthy and strong as possible. Following the plan will
help you feel better and live longer. We will give you a list of medication, what time you will take the medication and how many time a day.
Follow-up
-The patient is encouraged to visit attending physician as prescribed for follow-up check-up upon discharge.