CUES NURSING OBJECTIVES INTERVENTIONS

NURSING CARE PLAN RATIONALE EVALUATION

DIAGNOSIS
Subjective Excess fluid After 8 hours of  Establish  To gain After 8 hours
cues: volume r/t nursing rapport. patient’s trust of nursing
“Di ako gayd decrease interventions, the and interventions,
pakalalakaw glomerular patient will: cooperation. the patient
ka gya mga filtration  Monitor and  To assess demonstrated
ae akn a rate and  Patient will record vital precipitating behaviors to
kil’l’bag.” As sodium demonstrate signs. and causative monitor vital
verbalized retention behaviors to factors. status but
by the monitor failed to
 Assess  To obtain
fluid status
patient. possible risk baseline data. stabilize her
and reduce
recurrence factors. fluid volume.
Objective of fluid
cues: excess  To obtain
BP: 150/100  Monitor and baseline data.
PR: 82 record vital
O2: 98 signs.  To note for
RR: 16  Assess presence of
T: 36.9 patient’s nausea and
appetite vomiting.
-Facial
grimace
-Limited  Note  To prevent
ROM amount/rate fluid overload
-Swelling of fluid intake and monitor
feet from all intake and
sources. output.

 Compare  To monitor
current fluid retention
weight gain and evaluate
with degree of
admission or excess.
previous
stated weight.

 To determine
 Note presence
fluid retention.
of edema.

 May indicate
 Evaluate
cerebral
mentation for
edema.
confusion and
personality
changes.
 Observe skin  To evaluate
mucous degree of fluid
membrane. excess.

 Change  To prevent
position of pressure
client timely. ulcers.

 Review lab  To monitor

data like BUN, fluid and
Creatinine, electrolyte
Serum imbalances.
electrolyte.

 Restrict  To lessen fluid

sodium and retention and
fluid intake if overload.
indicated.

 Record I&O  To monitor

accurately and kidney function
calculate fluid and fluid
volume retention.
balance.

 Encourage  To conserve
quiet, restful energy and
atmosphere. lower tissue
oxygen
demand.

 Promote  To promote
overall health wellness.
measure.