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Date Cues Need Nursing Goal of Care Intervention Plan Evaluation


07/0 Subjective: N Excess fluid At the end of 5 hours of 1. Assess for presence of
5/10 “Paminaw nako kay U volume related to nursing interventions, edema by palpating over tibia,
puno kaayo diri,” T compromised the patient will be able ankles, feet, and sacrum.
@ stated by Mr. S. R regulatory to stabilize fluid volume ® Pitting edema is manifested
I mechanism. as evidenced by: by a depression that remains
9:15 Objective: T after one’s finer is pressed
am -with IVF of I ® Fluid volume a. Balanced intake over an edematous area and
PNSS1L @ 60 O excess or and output; then removed.
cc/hr N hypervolemia b. Vitals signs
-abdominal girth: A occurs from an within normal 2. Monitor daily weight of the
90 cm L increase in total limits and; patient.
-ascitis body sodium c. Drain at least 1 ® Any change in weight is
-bipedal edema M content and an liter of urine at indicative of increase
-weak and sleepy E increase in total foley catheter. extracellular fluid volume.
-CXR shows pleural T body water. This
effusion A fluid excess 3. Monitor VS of the patient.
-(+) crackles B usually results ® Tachycardia and increased
-decreased Hb (94) O from compromised blood pressure are seen in
and Hct (0.28) L regulatory early stages. Elderly patients
-increase glucose I mechanisms for have reduced response to
in the blood. C sodium and water catecholamines, thus their
-Furosemide as seen in CHF, response to fluid overload
P kidney failure, and may be blunted, with less rise
A liver failure. in heart rate.
T Bibliography:
Gulanick, Meg, PhD, RN,
4. Auscultate for a 3rd sound.
E (2003).Nursing ® S3 sound is an early sign of
R Care Plan: Nursing pulmonary congestion.
Diagnosis &
N Interpretation.
Westline Dive St.
Louise. Mosby Inc.
5th ed, p. 65
5. Monitor for distended neck
veins and ascites.
® Distended neck veins mean
increase pressure in the
jugular veins brought about
by increased circulating fluid.
6. Monitor abdominal girth daily.

7. Monitor input an output

® Although overall fluid intake
may be adequate, shifting of
fluid out of the intravascular
to extravascular spaces may
result in dehydration.

8. Evaluate urine output in

response to diuretic therapy.
® Focus on monitoring the
response to the diuretics,
rather than the actual amount
voided. Fluid volume excess
in the abdomen may interfere
with the absorption of oral
diuretic medications.

9. Check urinary catheter for

presence of urine.
® Treatment focuses on
diuresis of excess fluid

10. Instruct patient

regarding fluid restrictions as
® Facilitates reduction of
extracellular volume.

11. Instruct patient to

take diuretics as prescribed.
® Diuretic therapy may
include several different types
of agents for optimal therapy,
depending on the acuteness
or chronicity of the problem.

12. Note medications

that may cause fluid retention,
such as non-steroidal anti-
inflammatory agents,
vasodilators, and steroids.

13. Instruct to avoid

crossing of legs

® Reduce constriction of
vessels thus preventing

14. Assist patient in

repositioning every 2 hours
® Prevent accumulation of
fluid in dependent areas.