NURSING CARE PLAN

ASSESSMENT S> 0 O> > Generalized edema > difficulty of breathing >shortness of breath >Vital Signs taken as follows: BP-150/80 mmHg T-37 P-81 R-26 NURSING DIAGNOSIS SCIENTIFIC EXPLANATION
PLANNING

NURSING INTERVENTIONS
Assess patients condition Record Intake and Output

RATIONALE
For baseline data Accurate I and O is necessary for determining renal function and fluid replacement needs and reducing risk of fluid overload Fluid management is usually calculated to prevent further fluid retention Daily body weight is best monitor of fluid status To determine fluid retention To prevent pressure ulcers May indicate increase in fluid retention May indicate cerebral edema To excrete excess fluids

EXPECTED OUTCOME Goal met as manifested by patient was able to demonstrate behaviors to monitor fluid status and reduce recurrence of fluid excess stabilizefluid volume AEB balance I & O, normal VS, stableweight, and freefrom signs of edema.

Fluid Volume Excess related to inability of the kidneys to maintain body fluid balance.

Renal failure blood flow to the kidneys perfusion in kidney urinary output water retention Fluid volume excess

After 8 hours of nursing intervention ,the patient shall demonstrate behaviors to ` monitor fluid status and reduce recurrence of fluid excess

Restrict fluids

Weigh patient daily at the same time each day Record occurrence of dyspnea Change position of client timely Note presence of edema Evaluate mental status Administer Diuretic as ordered

After 24-48 hours of nursing intervention, the patient will manifest stabilizefluid volume AEB balance I & O, normal VS, stableweight, and freefrom signs of edema.

Administer Anti hypertensive as ordered

To treat hypertension by counteracting effects of decreased renal blood flow

and/or circulating volume overload