Nursing Process

Assessment Diagnosis Goal Planning Implementation Rational Evaluation

Swelling of Excess fluid Patient will - assess weight, - weight, auscultation -to determine the fluid My goal was
face and volume maintain lungs sounds lung for sounds and volume so that fully met as
hand related to fluid volume and extremities press extremities for treatment parameters patient
fluid status within for presence of presence of oedema. can be indentified maintain an
accumulation established oedema intact skin
between parameters -monitor intake -was monitored - poor oral intake but
CAPD output chart. need to monitor
treatment -monitor the -was monitored -to monitor the level so
laboratory data that the intervention
can take place
- teach patient - sodium can lead to
- the need for restricting
to restricting excessive fluid intake
sodium intake and subsequent
hypovolemia
Assessment Diagnosis Goal Planning Implementation Rational Evaluation
Malaise and Poor oral Patient can -asses weight Weight patient To get loss weight My goal was
lethargic intake due to eat with patient and intake patient can eat
loss of proper output chart as normal with
appetite dietary plan -let patient tell why Listen to patient So can planning good oral
loss appetite intake
- ask patient which Indent diet that Patient will try to eat

food will she will patient need because of her

prefer to eat favourite foods

example chicken
Clear patients place Create the situation to
- avoid all
distracted objects patient eat

-advice patient’s Some patient only like

Allowed family
family member to eat home foods
member to bring
bring foods from
foods for patient
the house but
make sure healthy
Tell her the important Ensure patient
-encourage patient
of oral intake
to eat and advice
her to take foods
Assessment Diagnosis Goal Planning Implementation Rational Evaluation
Impaired Impaired Patient can -assess mobility of Observe patient To planning the Patient can do
mobility mobility due accomplish patients intervention her routine
to below knee daily routine - advice patient to Schedule the routine Better be slow then not work
amputation work do daily activity activity
and fluids at slowly without
peritoneal rushing
-keep the closer the Keep the things Patient can get it easy

routine thing patient used to be

use close to
achievable place
Request relatives to Can complete routine
- Advise relative to
keep help patient to work in time and also
help patient
complete routine can prevent from fall

work
- teach patient to Can prevent from fall
Now patient using
use effective and also can go faster
walking frame, can
walking aids to certain place.
change to wheelchair
for certain place