Assessment Subjective: Namamaga ang mga binti at paa ko as verbalized by the patient.

Objective: - Presence of edema in both lower Extremities. Vital signs: BP- 150/90 PR- 95 RR- 22 T- 37.3 C

Nursing Diagnosis Fluid Volume Excess related to sodium retention as manifested by presence of edema in both lower extremities.

Planning After 8 hours of nursing interventions, patient will verbalize understanding of the measures to prevent and lessen fluid volume excess.

Nursing Intervention - Establish rapport

Rationale - To assess precipitating & causative factors. - To obtain baseline data.

- Monitor and record vital signs.

Evaluation After 8 hours of nursing interventions, patient verbalized understanding of measures to prevent and lessen fluid volume excess.

- Compare current weight - To obtain baseline gain with admission or data previous stated weight. - Discuss the following measures to prevent and lessen fluid volume excess: a) Advise patient to elevate feet when sitting down. b) Instruct patient regarding restricting fluid intake. - This prevent and lessen fluid accumulation in lower extremities - Intake of fluid up to 500ml is equivalent to 0.5 kg. Increase in weight due to fluid retention. Therefore limiting is necessary to avoid fluid retention.

c) Instruct patient regarding the restricting dietary sodium intake. d) Administer diuretics (Furosemide) to relieve excess fluid volume as prescribed by the physician. e) Encouraged compliance to Dialysis treatment as indicated.

- Sodium intake produces a feeling of thirst. This causes increase in the intake of fluid. - Diuretics enhances the excretion of both sodium and chloride in the urine so that water follows and also excreted thus fluid overload is prevented. - This maintains fluid balance by osmosis and eliminates fluid and waste products I n the kidney.