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Nursing Analysis Goals & Nursing Rationale Evaluation

Diagnosis and Objective Intervention


Cues
Fluid volume Excess fluid Goal: Supplemental and The goal was
excess related volume can After 3 days of Facilitative: met as
to presence of lead to nursing • Regularly • Prompt manifested by
fluid in the lung pulmonary interventions monitor client’s recognition of stabilized
and excessive congestion the client will respiratory rate deteriorating fluid as
sodium intake leading to be able to have and pattern and respiratory evidenced by:
respiratory stabilized fluid signs of edema. function can a. Absence of
Subjective: distress. volume as • Monitor vital reduce edema on
• The client Pleural evidenced by signs. potentially lethal upper and
verbalized “ effusion is absence of outcomes. lower
for breakfast an edema, • Frequently • Hourly extremities
usually 1 cup accumulatio hematocrit record intake recording of .
of milk muna n of fluid in level within the and output. intake and b. Clear lung
then kakain the pleural normal range output serves as sounds on
ako ng space. and clear lung a baseline for the left
corned beef Pleural fluid sounds. assessing fluid lower lung
or tuna pero normally • Auscultate imbalances. upon
hindi ko na seeps Objectives: breath sounds. • This will note auscultatio
yun niluluto continually After 3 days of the presence of n.
tapos yung into the nursing • Update all crackles/congesti c. Hematocrit
rice pleural interventions the laboratory on. level within
sasabawan space and is the client will records. • Laboratory the normal
ko ng toyo, reabsorbed be able to: results evaluate range (M:
yung nasa by the 1. Have a the degree of 0.40-50g/l)
pack, mga ¼ visceral stabilize fluid fluid and d. RR within
nun pag hindi pleural volume as • Assist client electrolyte normal
ako capillaries evidenced in a Semi- imbalance. range.
nakuntento and by: e. Good skin
Fowler’s • The upright
nilalagyan ko lymphatic a. Absence position. turgor.
position allows
pa sya ng system. Also of edema on
suka excess fluid upper and full lung
hangggang volume lower excursion and
sa maghalo results from extremities. • Monitor the enhances air
yung alat at renal b. Clear client's behavior exchange.
asim.” disorders lung sounds for restlessness, • When excess
• “Nakaka 1 that impair on the left anxiety, or fluid volume
liter din ako glomerular lower lung confusion; use happens, the
ng softdrinks filtration of upon safety client will
(coke) each sodium and auscultation. precautions if experience
meal.” water. Signs c. Hematocr symptoms are cerebral tissue
Objective: and it level present hypoxia, and the
• Bilateral symptoms within the client may
pedal edema, may include normal • Carry out demonstrate
grade 1 dyspnea, range (M: medications that restlessness and
• Minimal edema, 0.40-50g/l) help in removing anxiety.
sounds of decreased d. RR within fluids in the • Diuretics and
crackles are hematocrit normal body such as plasma or
heard during level and range. diuretics and albumin volume
auscultation rapid weight e. Good skin plasma or expanders are
particularly gain. turgor. albumin volume some of the
on the left Excessive expanders. medications that
lower lung. amounts of may help
• Skin springs such fluid Developmental: decrease excess
back but it can impair • Teach client fluid in the body.
takes a time breathing by the importance
of 5 seconds. limiting the of fluid and
• Decreased expansion of sodium • Restriction of
hematocrit the lungs restriction. fluid and sodium
level (0.38/L) during • Encourage intake help in
• BMI=27.15 inhalation. frequent oral maintaining fluid
• Respiratory (Black and care. balance.
rate is 24. Hawks. • This will
Medical reduce
Surgical discomfort of
Nursing 8th fluid restriction.
ed. Volume
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