COR JESU COLLEGE, INC.

,
College of Health Sciences
Sto. Rosario, Tres De Mayo, Digos City

NURSING CARE PLAN NO. 1

DATE/ CUES/ DATA NURSING SCIENTIFIC GOALS/ NURSING RATIONALE EVALUATION

TIME DIAGNOSIS BASIS OBJECTUVE/ INTERVENTION
CRITERIA
11/20/23 Objective: Excess fluid volume Heart failure results Within 8 hours of 1. Regularly monitor vital 1. Regularly monitor vital Within 8 hours of nursing
8AM-3PM - Edema in both related to sodium in poor perfusion nursing intervention the signs, signs of fluid signs, signs of fluid intervention the patient was
overload (edema, overload (edema,
lower extremities intake as evidence by of the kidneys. If patient will be able to: able to:
distended neck veins, distended neck veins,
- weakness edema in both lower the kidneys cannot 1. demonstrate a shortness of breath), shortness of breath), 1. demonstrated a reduction
- activity extremities excrete sodium, reduction of edema, and and accurate intake and and accurate intake and of edema, and exhibit a
output. output.
intolerance water retention will exhibit a reduce in reduce in swelling.
2. Collaborate with the 2. Restricting fluid intake
- type II Diabetes occur and swelling. healthcare team to helps prevent further 2. achieved balance fluid
Mellitus accumulate in establish and fluid accumulation,
2. maintain cardiac implement a fluid reducing the workload intake and output.
-weight 50 kg tissues leading to
output. restriction plan; educate on the heart and
- cardiac output fluid overload. 3. verbalized dietary
the patient and family improving overall fluid
3.58 L/min 3. achieve balance fluid about adherence. balance. recommendations and fluid
intake and output. 3. Administer diuretics as 3. Diuretics increase urine restrictions to maintain.
prescribed to promote output, reducing excess
(Maegan Wagner, 4. verbalize dietary diuresis and fluid fluid. Monitoring for
BSN, RN, CCM, recommendations and elimination; monitor side effects ensures
for side effects. patient safety during PARTIALLY MET
2023) fluid restrictions to
4. Weigh the patient daily pharmacological
maintain. and report significant interventions.
weight gains promptly. 4. Daily weights are an
5. Elevate the legs to effective way to
reduce dependent monitor fluid balance.
edema; encourage Sudden weight gains
frequent position may indicate fluid
changes. retention and require
prompt attention.
5. Elevation of the legs
promotes venous return
and reduces edema.
Position changes
prevent pressure ulcers
and enhance overall
comfort.