NURSING

RATIONALE OF
NURSING GOAL & OUTCOME ACTIONS &
ASSESSMENT SCIENTIFIC BASIS NURSING EVALUATION
DIAGNOSIS CRITERIA NURSING
ORDERS
ORDERS

SUBJECTIVE: Fluid Volume Renal disorder impairs After 3 hours of nurse-  Assess client’s  To obtain After 3 hours of

“Nang hupong Excess R/T glomerilar filtration that patient interaction, level of edema. baseline data nurse-patient

ang nawng sa decrease resulted to fluid overload. patient’s mother will be interaction, patient

akong anak sir” Glomerular With fluid volume excess, able to:  Assess possible  To obtain was able to:

as verbalized by filtration Rate and hydrostatic pressure is higher  Identify individually risk factors baseline data  Identify

the mother sodium retention than the usual pushing excess appropriate individually

filtration Rate as fluids into interstitial spaces. interventions to appropriate

OBJECTIVE: manifested by Since fluids are not alleviate her son’s  Assess patient’s  To prevent interventions to

Presence of presence of edema reabsorbed at the venous end, condition. appetite fluid overload monitor fluid

edema in upper in upper fluid volume overloads the  Explain at least two and monitor status and

extremities. extremities. lymph system and stays in the management in intake and reduce

interstitial spaces leading the managing edema. output recurrence of

patient to have edema, weight  Identify factors that  Note amount/rate  To monitor fluid excess.

gain, pulmonary congestion could worsen the of fluid intake fluid retention  Explain at least

and HPN at the same time due condition. from all sources. and evaluate two

to decrease GFR, nephron degree of management in

hyperthropized leading to excess managing

decrease ability of the kidney  Restrict sodium  To monitor edema.

to concentrate urine and and fluid intake if kidney  Identify factors

impaired excretion of fluid indicated. function. that could

thus leading to . worsen the

oliguria/anuria. condition.

(Kozier and Erb’s  GOAL WAS

Fundamental in nursing 2016, MET

10th edition)