Date: July 11, 2011

Cues Subjective/ Objective

Objective: >Edema, grading edema of 2+ disappears 10-15 secs. Subjectives: >Restlessness >wt: 145lbs

Patients problem/ Nursing Diagnosis Fluid volume excess related to compromise d regulatory mechanism as evidenced by tissue edema

Analysis of patients problem

Theres an increase fluid retention an amount or quantity of fluid beyond what is normal or sufficient to our body.

Objective

Nursing Intervention / Implementation Nursing Nursing Actions Order

> To evaluate degree of excess >Evaluate mentation

Rationale of Interventi on
>For confusion or personality changes

Evaluatio n
Goal was met after 2-3 hours of nursing interventions patient was able verbalized understandin g of individual dietary/fluid restriction.

After 23hours of nursing interventions patient will be able to verbalize understandin g of individual dietary/fluid restrictions

> To Promote mobilization/el imination of excess fluid

>Restrict Na and fluid intake

> To emphasize dietary/fluid restriction

>Advised to elevate the edematous extremities, change position frequently > To promote wellness >Stress the need for mobility and frequent position changes

> To reduce tissue pressure and risk for skin breakdown

>To prevent stasis and risk of tissue injury

>Identify signs requiring notification of healthcare provider

>To ensure timely evaluation/int ervention