DANDAN, Margareth Joy A.

NCM109a
BSN 2B

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective Data: Excess fluid volume Short term goal: Independent: Short term goal:
related to After 1 hour of 1. Establish rapport. 1. To gain the client’s After 1 hour of
Objective Data: compromised nursing intervention cooperation. nursing intervention
 Hematuria regulatory the client will be able 2. Assess precipitating 2. To have a baseline the client was able to
 Proteinuri mechanism (AGN) to verbalize factors: data. verbalize
a as evidenced by understanding of a. Medical a. That can understanding of
 Edema of hematuria, individual dietary and conditions contribute to individual dietary and
both proteinuria, severe fluid restrictions. b. Determine excess fluid fluid restrictions.
eyelids edema of both amount of intake.
and lower eyelids and lower Long term goal: fluid intake. b. Potential Long term goal:
legs. legs, and blood After 3 days of c. Review exists for After 3 days of
 BP: 160/92 pressure level of nursing intervention nutritional fluid overload nursing intervention
mmHg 160/92 mmHg. the client will be able status. due to fluid the client was able
to: shifts and to:
 Stabilize fluid changes in  Stabilize fluid
volume as electrolytes volume as
evidence by balance. evidence by
balance input c. Imbalances in balance input
and output, vital these areas and output, vital
signs within are signs within
client’s normal associated client’s normal
limit, stable with fluid limit, stable
weight, and free imbalances. weight, and free
of signs of 3. Closely monitor vital 3. High blood pressure of signs of
edema. signs every 4 hours, contributes to kidney edema.
 Demonstrate especially the client’s damage.  Demonstrate
behaviors to blood pressure. behaviors to
monitor fluid monitor fluid
status and 4. Restrict fluid and 4. Restricting sodium status and
reduce sodium intake. favors renal excretion reduce
recurrence of of excess fluid and recurrence of
fluid excess. may be more useful fluid excess.
than fluid restriction.
5. Calculate input and 5. So that adjustments
output accurately in can be made in the
24-hour fluid balance. following 24-hour
intake if needed.
6. Set an appropriate 6. To prevent
rate of fluid intake exacerbation of
throughout 24-hour excess fluid volume
period. and peaks and valleys
in fluid level.
7. Weigh daily and 7. This provides a
compare current comparative baseline
weight with admission and evaluates the
or previously stated effectiveness of
weight. diuretic therapy
when used.
8. Elevate edematous 8. To reduce tissue
extremities and pressure and risk of
change position skin breakdown.
frequently.

Dependent:
1. Administer 1. To reduce congestion
medications. and edema if heart
a. IV furosemide. failure is cause of
b. Oral fluid overload. Also,
amlodipine. to treat high blood
pressure.