St.

Paul College of Ilocos Sur

(Member: St. Paul University System)
St. Paul Avenue, 2727 Bantay, Ilocos Sur

Name: Charisse U. Adalla_ Instructor: Mr. Goldwyn A. Adversalo, RN

Section/Year Level: BSN-IA Date: 03/19/2022

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: “namamaga ang The patients fluid volume After 8 hours of nursing Independent: Independent After receiving nursing care
binti at paa ko” as excess related to sodium intervention the patient will  Monitor the patient  Despite the fact that for 8 hours, the patient
verbalized by the patient retention as manifested by be demonstrate stabilized intake and output in edema still exists, displayed stabilized fluid
presence of edema in both fluid and verbalize the 24 hours. diuretic therapy volume, clear breath
Objective: Presence of lower extremities. understanding of the  Weigh daily may cause sounds, vital signs within
edema in both lower measure to prevent and  Monitor BP excessive fluid loss. acceptable range, stable
extremities lessen fluid volume excess.  Note increased body  Records edema weight, and no signs of
fluid volume resolution or change edema.
Vital Sign:  Review patients in response to
BP- 140/90 mmHg laboratory data treatment
PR- 90 bpm  Hypertension
RR- 22 bpm Dependent: suggests excess
Temp.- 37.8 C  By the doctors order fluid volume, which
administer could contribute to
medications the development of
 Maintain fluid/ heart failure.
sodium restrictions  In the body, water
as indicated. follows sodium, so
a high sodium level
will also result in a
high water level.
 Evaluate the level of
fluid volume
Collaborative: imbalance and
 Collaborate to a treatment
dietician as needed. effectiveness.

Dependent
 Maintain acceptable
level of medication

 Reduces body water

overall and prevents
fluid retention.

Collaborative
 To promote
optimum health