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NUSING DIAGNOSIS Subjective cues: Fluid Volume Excess related to tikang naospital hiya talagudti nala compromise regulatory

y an iya ihi, asya mechanism (renal gincatheter na failure) hiya as verbalized by the S.O. Objective cues: BP: 140/90 Edema @ both arms noted Pulmonary congestion on xray 10cc urine output, 3x a day


SCIENTIFIC RATIONALE Fluid volume excess or hypervolemia, occurs from increase in total body sodium content and increase in total body water. This fluid excess usually results from compromised regulatory mechanisms for sodium and water has seen in congestive heart failure, kidney failure, and liver failure. It may also ba caused of excessive intake of sodium from foods, intravenous IV solution, medications, or diagnostic contrast dyes. Hypervolemia may be an acute or chronic condition managed in hospital, out-patient center, home setting. The therapeutic goal is to treat underlying disorder and return the extracellular fluid compartment to normal. Treatment consist of fluid and sodium restriction of the use of diuretics.

OBJECTIVES Short Term: After 4-8 hours of nursing interventions, patient will demonstrate behaviors to monitor fluid status and reduce recurrence of fluid excess

NURSING INTERVENTIONS 1. Establish rapport

RATIONALE 1. To gain trust and confidence to the client. To assess precipitating and causative factors. 2. To obtain baseline data 3. To obtain baseline data . 4. To note for presence of nausea and vomiting 5. To prevent fluid overload and monitor intake and output 6. To monitor fluid retention and evaluate degree of excess 7. For presence of crakles or congestion

EVALUATION Short Term: After 4-8 hours of nursing interventions, patient had demonstrate behaviors to monitor fluid status and reduce recurrence of fluid excess

2. Monitor and record vital signs 3. Assess possible risk factors

4. Monitor and record vital signs.

5. Assess patients appetite

6. Note amount/rate of fluid intake from all sources

7. Compare current weight gain with admission or previous stated weight

8. To evaluate

Reference: Nursing Care Plan by Myers 6th ed, page 74

8. Auscultate breath sounds 9. Record occurrence of dyspnea 10. Note presence of edema.

degree of excess 9. To determine fluid retention 10. May indicate increase in fluid retention 11. To evaluate degree of fluid excess.

11. Evaluate mentation for confusion and personality changes. 12. Observe skin mucous membrane. 13. Change position of client timely.

12. To prevent pressure ulcers.

13. To monitor fluid and electrolyte imbalances 14. To lessen fluid retention and overload. 15. To monitor kidney function and fluid retention. 16. Weight gain indicates fluid retention or edema.

14. Review lab data like BUN, Creatinine, Serum electrolyte. 15. Restrict sodium and fluid intake if indicated 16. Record I&O accurately and calculate fluid

volume balance 17. Weigh client 17. Weight gain may indicate fluid retention and edema. 18. To conserve energy and lower tissue oxygen demand. 19. To promote wellness.

18. Encourage quiet, restful atmosphere.

19. Promote overall health measure