UNIVERSITY OF NUEVA CACERES

Nursing Care Plan

Form
College of Nursing

Name:Acob & Casillan Year & Section: 2B Area: City Health Office 1 Schedule: Mon to Wed., 12:00 - 5:00 pm CI: Noel Sta. Isabel, RN

ASSESSMENT N-DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Fluid Volume Excess Fluid volume Short Term: Independent: Short term: Goal
- r/t compromised renal excess in After 2 hours of nursing 1. Monitor the patient’s vital 1. This will be used as met
function as evidenced individuals with interventions, the patient signs: blood pressure, the baseline data for
by edema and weight heart rate, respiratory the patient’s
Objective Data: renal failure is will be able to: After 2 hours of
gain rate, and O2 saturation, condition at the time
(+) oliguria caused by as well as weight. being. nursing interventions,
(+) weight gain of 12 lbs compromised a. verbalize 2. Monitor signs of fluid 2. Recognizing that the patient was able
(c) crackles upon kidney function, awareness of overload such as: edema can be the to verbalize
auscultation which results in causative factors edema, weight gain, and cause or result of a awareness of
(c) bilateral pedal edema decreased water and behaviors increased blood pressure variety of clinical causative factors and
+2 and sodium essential to 3. Weigh in daily. disorders, as well as behaviors essential
4. Position the client to a assessing its
(c) altered LOC excretion. This fluid correct fluid to correct fluid
comfortable position. severity and
(+) restlessness; retention causes excess 5. Assess the patient’s level distribution, aids in excess; displayed
dyspnea an increase in b. display little to of consciousness. determining the little to reduced signs
(+) tachycardia extracellular fluid reduce signs of efficacy of fluid of bilateral pedal
volume, which can bilateral pedal management edema; and
Vital Signs: lead to edema, edema measures and exhibited
HR: 140 bpm hypertension, and c. exhibit guiding future normovolemic as
RR: 14 bpm treatment decisions.
cardiac problems. normovolemic as evidenced by urine
O2 Sat: 93% 3. It is believed that
Managing fluid evidenced by monitoring and output greater than
volume is critical in urine output recording daily or equal to 30 cc/hr
these people to greater than or weights at the same
prevent further equal to 30 cc/hr time every day, using
harm and preserve the same scale, to
correctly monitor
good health.
fluid status. Promptly
Long Term: report any major Long Term: Goal
After 8 hours of nursing weight increase or met
interventions, the patient reduction. After 8 hours of
4. Encourage or aid
will be able to: nursing interventions,
with positioning,
such as lifting the the patient was able
a. show reduced head of the bed and to show reduced
signs of bipedal raising the legs signs of bipedal
edema when sitting, to edema; displayed a
b. display a normal increase venous normal fluid volume
fluid volume AEB return and minimize AEB balance of
dependent edema.
balance of intake intake and output
5. Fluid volume excess
and output or deficit, which is especially in urine
especially in Dependent; prevalent in renal with 30 cc/hr; and
urine with 30 1. Administer oral fluids failure, can have an presented with clear
cc/hr with caution. Do a 24-hr impact on breath sounds and a
c. present with schedule fluid intake for consciousness. normal VS (RR &
clear breath fluid restriction. Severe fluid HR) within
2. Promote sodium and overload can
sounds and a acceptable ranges
fluid restriction as produce cerebral
normal VS (RR indicated. edema and elevated for age and condition
& HR) within 3. Insert indwelling catheter intracranial pressure.
acceptable as indicated.
ranges for age 4. Administer diuretics as
and condition indicated: loop diuretics 1. If the local water
such as furosemide, source contains a
potassium-sparing high concentration of
diuretics such as sodium, clients must
spironolactone, and use distilled water.
thiazide diuretics such as Bottled water's salt
hydrochlorothiazide. level can range from
0 to 1200 mg/liter.
2. Restriction of salt
and fluid becomes
crucial in the
management of
oliguric kidney
failure, wherein the
kidneys do not
adequately excrete
either toxins or
fluids. Oliguric

2
 clients should also
have a fluid
restriction of 400 ml
plus the previous
day’s urine output
unless there are
signs of volume
depletion.
3. Catheterization
excludes lower tract
obstruction and
provides means of
accurate monitoring
of urine output
during the acute
phase.
4. Diuretics are used to
treat edema when
dietary sodium
restriction alone is
insufficient. They
work by decreasing
the kidneys'
reabsorption of
sodium and water.
The choice of
diuretic is
determined by the
severity of the
hypervolemic state,
the degree of renal
function impairment,
and the diuretic's
efficacy.

Collaborative:
1. Prepare the client for 1. Acute or urgent
dialysis. dialysis is
recommended when
serum potassium
levels are high and
rising, fluid overload
is present, or
pulmonary edema is
imminent. Chronic or
maintenance dialysis
is recommended for
advanced CKD and
ESKD patients with
fluid overload that
does not respond to
diuretics or fluid
restriction.