PRIORITIZATION OF NURSING CARE PLANS
DIAGNOSIS
Fluid Volume Excess
related to compromised
regulatory mechanism
(acute kidney injury)
Ineffective breathing pattern
related to decreased lung
expansion secondary to fluid
accumulation
Risk for Injury related to
abnormal blood profile
CUES JUSTIFICATION
Bipedal edema
Fluid volume excess (FVE), or hypervolemia, refers to an isotonic
Oliguria
expansion of the ECF caused by the abnormal retention of water and
Azotemia
sodium in approximately the same proportions in which they normally
Hypokalemia
exist in the ECF. (Brunner and Suddarths Textbook of Medical-Surgical
(+) Crackles
Nursing 12th Edition. 2016. Page 273)
Neck vein distention
Dyspnea
Ineffective breathing patterns and shortness of breath are due to the
Tachypnea
ineffective respiratory mechanics of the chest wall and lung resulting from
(+) Crackles
air trapping, ineffective diaphragmatic movement, airway obstruction, the
Changes in depth of respirations
metabolic cost of breathing, and stress. (Brunner and Suddarths
Use of accessory muscles
Textbook of Medical-Surgical Nursing 12th Edition. 2016. Page 612)
Abnormal ABGs
Presence of hematomas Vulnerable for injury as a result of environmental conditions interacting
Prolonged PT and aPTT with the individuals adaptive and defensive resources, which may
Decreased hemoglobin and compromise health. (Wayne, 2016)
122
 hematocrit

Extremes of age

In older adults, the skin has diminished epidermal thickness, dermal

Braden scale score of 14
Risk for Pressure Ulcers collagen, and tissue elasticity. The skin is drier as a result of diminished
Decreased hemoglobin and
related to prolonged sebaceous and sweat gland activity. (Brunner and Suddarths Textbook
hematocrit
immobility of Medical-Surgical Nursing 12th Edition. 2016. Page 185)
Bipedal edema

123
 NURSING BACKGROUND PLAN OF CARE/ NURSING
ASSESSMENT RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE GOAL INTERVENTION

Objective: Excess Fluid Excessive sodium SHORT TERM 1. Note presence of 1. These may contribute to GOAL
Non-pitting Volume related and/or water intake GOALS: medical conditions or excess fluid intake or retention. PARTIALLY MET.
bipedal edema situations. (Doenges, et. al. Nurses Pocket
to After 1 hour of
Oliguria Guide 14th Edition. 2012. Page
Patient was able to
compromised nursing
Dyspnea Decreased 339-340)
regulatory interventions, the verbalize
Restlessness excretion of wastes
mechanism patient will: 2. Determine or 2. Accurate I&O is necessary for understanding
(+) Crackles on
upper thorax, (acute kidney estimate the amount determining fluid replacement regarding
bilateral injury) 1. Verbalize of fluid intake from all needs and reducing risk of fluid implementation of
Kidneys receive sources. Record overload. (Doenges, et. al.
Neck vein signal to save understanding of interventions such
distention accurate intake and Nursing Care Plans: Guidelines as dietary and fluid
sodium and water individual dietary
output. for Individualizing Client Care
and fluid restrictions,
Laboratory and to compensate for Across the Life Span, 8th Edition.
restrictions 2010. Page 542) elevation, and
Diagnostics: failure
medications.
Anemia
LONG TERM 3. Observe skin and 3. Edematous tissues are prone Patients vital signs
Decreased
Overhydration GOALS: mucous membranes. to ischemia and breakdown or were also within
hemoglobin
After 2 days of Note the presence of ulceration. Heart failure and renal her normal limits.
(99g/L; normal is
edema, anasarca. failure are associated with However, urine
130-170 g/L) - 7 nursing
Fluid shifts into dependent edema becase of
August 2017 interventions, the output remained
hydrostatic pressures, with
Decreased interstitial spaces patient will: low, laboratory
dependent edema being a
hematocrit studies remained
defining characteristic for excess
(0.297; normal is
1. Stabilize fluid fluid. (Doenges, et. al. Nurses abnormal, and
0.40-0.54) - 7 Excess fluid
volume as Pocket Guide 14th Edition. 2012. presence of edema
August 2017 volume Page 340-341) remained as well.
Azotemia: evidenced by
Increased BUN balanced input and 4. Measure vital signs 4. Pressures may be high
(16.30; normal is output (I&O), vital and invasive because of excess fluid volume
2.5-7.2 mmol/L) signs within clients hemodynamic or low if cardiac failure is
and Creatinine parameters, as occurring. (Doenges, et. al.
normal limits,
(434.40; normal indicated. Nurses Pocket Guide 14th
is 71-115 stable weight, and
free of signs of Edition. 2012. Page 340-341)
umol/L) - 6
August 2017 edema.

124
 ABGs: 5. Auscultate breath 5. For presence of crackles,
Compensated 2. Display sounds. congestion. (Doenges, et. al.
Metabolic appropriate urinary Nurses Pocket Guide 14th
Acidosis with Edition. 2012. Page 340-341)
output with
Adequate
laboratory studies Collaborative:
Oxygenation -
6 August 2017 near normal; stable 6. Restrict fluid intake 6. Restricting sodium favors renal
KUB Ultrasound: weight and vital as indicted. Provide excretion of excess fluid volume
Renal signs within for sodium and to prevent peaks and valleys
Parenhymal patients normal restrictions if needed. in fluid level. (Doenges, et. al.
Disease - 4 limits; and absence Nurses Pocket Guide 14th
August 2017 Edition. 2012. Page 341)
of edema
7. Administer 7. Reduce congestion and edema
medications, such as if heart failure is the cause of fluid
diuretics and plasma overload. (Doenges, et. al.
or albumin volume Nurses Pocket Guide 14th
expanders (20% Edition. 2012. Page 341)
Human Albumin +
40mg Furosemide
TIV Q24H)
8. If renal function is so severely
8. Prepare for and impaired that pharmacologic
assist with dialysis, if agents cannot act efficiently,
necessary. other modalities are considered
to remove sodium and fluid from
the body. (Brunner and
Suddarths Textbook of Medical-
Surgical Nursing 12th Edition.
2016. Page 274)

125
 NURSING BACKGROUND PLAN OF CARE/ NURSING
ASSESSMENT RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE GOAL INTERVENTION

Subjective Cues: Ineffective Abdominal wall SHORT TERMS 1. Note respiratory 1. This provides insight into the GOAL
Yes. It is hard for breathing excursion during GOALS: rate, depth, use of work of breathing and adequacy PARTIALLY MET
me to breathe pattern related inspiration, After 8 hours of accessory muscles, of alveolar ventilation.
sometimes. Its to decreased expiration does nursing pursed-lip breathing; (Doegenes, M., Moorhouse, M., Patient was able to
like I am always lung expansion not maintain interventions, areas of Murr, A.,Nursing Care Plan, 8th demonstrate
gasping for air.
secondary to optimum patient will: pallor/cyanosis, such edition page 359.) improved
So I have to rest
or pahinga muna fluid ventilation as peripheral versus ventilation and
after talking. As accumulation 1. Maintain an central or general oxygen saturation
verbalized by the effective breathing duskiness. levels were
patient. pattern, as
Altered rate, maintained within
evidenced by
depth, timing, and relaxed breathing 2. Assist the patient 2. Elevation or upright position normal levels. The
Objective Cues: rhythm, or pattern at normal rate and in semi-fowlers facilitates respiratory function by patient also was
(+) Crackles on of breathing depth and absence position. gravity; however, a client in able to participate
upper thorax, of dyspnea; severe distress will seek a in treatment
bilateral
position of comfort. (Doegenes, regimen. However,
Neck vein 2. Demonstrate
distention Ineffective M., Moorhouse, M., Murr, the patient wasnt
comfortability when
Alteration in breathing pattern A.,Nursing Care Plan, 8th edition able to verbalize
breathing; and
respiratory page 360.) the awareness of
pattern (24 cpm; 3. Perform causative factors.
normal is 15-20 diaphragmatic 3. Encourage deep- 3. This promotes optimal chest
cpm) pursed-lip breathing exercises expansion, mobilization of
breathing. such as pursed-lip secretions, and oxygen diffusion.
Alteration in
depth of breathing. (Doegenes, M., Moorhouse, M.,
LONG TERM
respiration Murr, A.,Nursing Care Plan, 8th
GOALS:
(shallow) After 2 days of edition page 360.)
Restlessness nursing
Use of accessory interventions, the
patient will: 4. Monitor pulse 4. To improve respiratory function
muscles to
oximetry, and vital / oxygen-carrying capacity.
breathe
signs as indicated. (Doegenes, M., Moorhouse, M.,

126
 1. Have ABG Murr, A.,Nursing Care Plan, 8th
Laboratory and levels return to and edition page 360)
Diagnostics: remain within
Decreased established limits. Collaborative
hemoglobin 5. Maintain 5. Pharmacological agents are
(99g/L; normal is supplemental oxygen. varied, specific to the client, but
130-170 g/L) - (1-2 liters per minute generally used to prevent and
7 August 2017
via nasal cannula) control symptoms, reduce
Decreased
hematocrit frequency and severity of
(0.297; normal is exacerbations, and improve
0.40-0.54) - exercise tolerance. (Doegenes,
7 August 2017 M., Moorhouse, M., Murr,
Abnormal Arterial A.,Nursing Care Plan, 8th edition
Blood Gas: page 361.)
Compensated
6. Administer
Respiratory
Alkalosis with medications as 6. To verify maintenance /
Adequate indicated: improvement in O2 saturation.
Oxygenation - N- (Doegenes, M., Moorhouse, M.,
7 August 2017 Acetylcysteine Murr, A.,Nursing Care Plan, 8th
600 milligram/ edition page 101)
sachet plus
100 milliliters
water once a
day for 5 days

127
 NURSING BACKGROUND PLAN OF CARE/ NURSING
ASSESSMENT RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE GOAL INTERVENTION

Risk Factors: Risk for injury Impaired renal SHORT TERM 1. Note the clients 1. These affect the clients ability GOAL MET.
related to functioning GOALS: age, gender, to protect self and/or others, and
Extremes of Age abnormal blood After 1 hour of
developmental stage, influence choice of interventions The patient
(77 years old) decision-making
profile nursing and teaching. (Doegenes, M., verbalizes
Presence of ability, and level of
understanding of
Hemodialysis interventions, the cognition / Moorhouse, M., Murr, A., Nurses
hematomas on factors that can
abdomen and patient will: competence. Pocet Guide, 14th edition, page
contribute to injury.
arms 481.)
During the shift,
Leukocytosis Risk for injury 1. Verbalize the patient also
(21.7 x 109/L; understanding of 2. Assess skin 2. Signs of infection, which can show no signs of
normal is 4.0 - individual factors around vascular progress to asepsis if untreated. injury and
10.0 x 109/L) 7 that contribute to access, noting
(Doegenes, M., Moorhouse, M., infection.
August 2017 possibility of injury; redness, swelling,
Murr, A.,Nursing Care Plan, 8th
Prolonged and local warmth,
exudate, and edition page 476.)
Prothrombin Time
(15.8 seconds; 2. Demonstrate tenderness.
normal is 10.6- behaviors, lifestyle
13.6 seconds) changes to reduce 3. Avoid 3. Prevents introduction of
Prolonged risk factors and contamination of organisms that may cause
Activated Partial protect self from access site. Use
infection. (Doegenes, M.,
Thromboplastin injury. aseptic technique and
masks when giving Moorhouse, M., Murr, A.,Nursing
Time (43.9
shunt care, applying Care Plan, 8th edition page 476.)
seconds; normal LONG TERM
is 25.3-32.3 and changing
GOALS:
seconds) dressing, and when
After 8 hours of starting and
Decreased
nursing completing dialysis
hemoglobin (99
g/L; normal is interventions, the process.
130-170 g/L) patient will:
7 August 2017 Collaboration:
4. Provides information about
1. Be free from 4. Monitor

128
 Decreased injury prothrombin time (PT) coagulation status, identifies
hematocrit (0.297; and activated partial treatment needs, and evaluates
normal is 0.40- thromboplastin time effectiveness. (Doegenes, M.,
0.54) 7 August (aPTT), as Moorhouse, M., Murr, A.,Nursing
2017 appropriate. Care Plan, 8th edition page 476.)

5. Administer
medications, as
inidcated, such as 5. Prompt treatment of infection
antibiotics. may save access and prevent
sepsis. (Doegenes, M.,
Moorhouse, M., Murr, A.,Nursing
Care Plan, 8th edition page 476.)

129
 NURSING BACKGROUND PLAN OF CARE/ NURSING
ASSESSMENT RATIONALE EVALUATION
DIAGNOSIS KNOWLEDGE GOAL INTERVENTION

Risk factors: Risk for Limitations in SHORT TERM 1. Identify presence of 1. Skin integrity problems can be GOAL MET.
Braden scale Pressure Ulcer activity and GOAL: underlying condition the result of disease processes
score of 14 related to mobility After 1 hour of that increases risk of that affect circulation and Patient displayed
(Moderate Risk) prolonged nursing pressure ulcer. perfusion, medications that healthy skin in risk
Non-pitting immobility interventions, the adversely affect or impair healing, areas during time
bipedal edema
Poor or inadequate patient will: burns, and nutrition & hydration. in care facility,
Extremes of age
(77 years old) nutrition (Doenges, et. al. Nurses Pocket participated in
Female gender 1. Verbalize Guide 14th Edition. 2012. Page prevention
Self-care deficit understanding of 662) measures and
Friction; Staying in a single risk factors and treatment program,
shearing forces position for long when to contact 2. Lift and avoid 2. To avoid shearing forces when and verbalized
Immobility periods of time healthcare dragging patients repositioning patients. Shifting understanding of
Impaired provider. across a surface. In weight allows the blood to flow risk factors and
circulation into the ischemic areas and helps
addition, small shifts of when to contact
Skeletal Skin constantly LONG TERM body weight, such as
tissues recover from the effects of
healthcare
prominence pressure. (Brunner and
against the bed GOALS: repositioning of an Suddarths Textbook of Medical- provider.
Changes in fluid
status sheets, which After 8 hours of ankle, elbow, or th
Surgical Nursing 12 Edition.
Decreased creates friction nursing shoulder, are 2016. Page 188 and 185) Kapag
hemoglobin (99 interventions, the necessary. nagsisimula na
g/L; normal is patient will: mamula yung balat
130-170g/L) Risk for pressure 3. Monitor for wetness niya, pwede na
7 August 2017 3. These can cause or
ulcer 1. Display and and moisture. Maintain yon maging bed
Decreased maintain healthy exacerbate skin breakdown.
that skin is clean, dry, sore kapag di
hematocrit (0.28; skin in risk areas, (Doenges, et. al. Nurses Pocket
normal is 0.40- and free of naagapan.
such as bony Guide 14th Edition. 2012. Page
0.54) 7 prominence and contaminants. Change (When her skin
663)
August 2017 skin folds, during diapers if necessary. starts to get red in

130
time in care color, it may
facility 4. Provide optimum develop into a bed
nutrition. 4. With adequate nutrition and sore if not given
2. Participate in
hydration, the skin can remain attention.) as
prevention
measures and healthy, and damaged tissues verbalized by the
treatment can be repaired (Brunner and patients significant
program, and Suddarths Textbook of Medical- other.
Surgical Nursing 12th Edition.
2016. Page 188)
5. Encourage range of
motion and
strengthening 5. Active and passive exercises
exercises. increase muscular, skin, and
vascular tone. (Brunner and
Suddarths Textbook of Medical-
Surgical Nursing 12th Edition.
6. Encourage regular 2016. Page 188)
inspection and
monitoring of skin for 6. Early detection and reporting to
changes or failure to healthcare providers promotes
heal. Educate patient timely evaluation and
and significant others intervention. (Doenges, et. al.
about the physical Nurses Pocket Guide 14th
cues for developing Edition. 2012. Page 664)
pressure ulcers.

131