Focus: Edema
S: Patient noticed presence of edema at the
F: Abnormal laboratory result
F: Nausea & Vomiting
Data:
lower extremities…………………………………………………
O: Remarkable for 2+ lower extremity edema
BP 180/110, HR 80 bpm RR 24cpm, Temp 36.8
O2 Sat 95%.............................................................
Action:
Independent:
Establish rapport…………………………………………………
Monitor I&O strictly……………………………………………
Advise patient to elevate feet when sitting down.
Instruct patient regarding restricting fluid intake.
Assess degree of peripheral edema…………………….
Dependent:
Administer furosemide to relieve excess fluid
volume as prescribed by the physician…………………
Response:
Pt. participated and tolerated therapy well………….
Theres still edema but is only 1+ degree in the
lower extremity…………………………………………………..
The patient is now comply on the instructions
given by the nurse and the physician…………………..
C. Torreon, RN 027847
D:
O - low sodium - 133 mmol/L
High Potassium – 6.2 mmol/L
High BUN – 170
High Creatinine 16.0
High Phosphorus – 10.5 mg/dl
A: independent
Establish rapport.
Monitor blood pressure, ensure the pt is adhering
to their treatment………………………………
Check urine for protein, labs for BUN and
creatinine…………………………………………………………
Dependent:
Doctors’ ordered peritoneal dialysis
R: Normal laboratory result
C. Torreon, RN 027847
D
O BP 180/110, HR 80 bpm, RR 24cpm, Temp
36.8, O2 Sat 95%.....................................................

F: Skin itchiness (pruritis)
A
Provide opportunity for patient to rest. Provide
clean and well-ventilated room. Monitor vital
signs. Encourage small frequent fluid intake.
Placed the client in an upright position. Assess
skin turgor. Instruct the pt. about the
medications. Keep emesis basin and oral care
things within reach……………………………………………
Dependent
Administer antiemetic medication like
metoclopramide 10 mg TIV as prescribed by the
doctor. Consult with doctor if symptoms
worsen………………………..…………………………………
R: The patient verbalized that there’s no
occurrence of vomiting and feeling nauseated.
C. Torreon, RN 027847
D:
S: Patient experience itchiness all over his body
O: superficial excoriations of his skin from
scratching………………………………………………………..
A:
Provide clean and comfortable environment.
Provide cool compresses. Educate the patient on
skin care. monitor for complications. Instruct the
patient to cut the nails in short to prevent
excoriations on the skin…………………………………..
Dependent:
Administer topical treatment like
diphenhydramine as prescribed by the doctor.
Inform the doctor if the excoriation of the skin
worsen……………………………………………………………..
C. Torreon, RN 027847