Date Cues Need Nursing

DiagnosisGoal of Care Intervention Plan Evaluation

07/05/10

@

9:15 am

Subjective:“Paminaw nako kay puno kaayo diri,” stated by Mr. S.

Objective:-with IVF of PNSS1L @ 60 cc/hr-abdominal girth: 90 cm-ascitis-bipedal edema-weak and sleepy-CXR shows pleural effusion-(+) crackles -decreased Hb (94) and Hct (0.28)-increase glucose in the blood.-Furosemide

NUTRITIONAL

METABOLIC

PATTERN

Excess fluid volume related to compromised regulatory mechanism.

® Fluid volume excess or hypervolemia occurs from an increase in total body sodium content and an increase in total body water. This fluid excess usually results from compromised regulatory mechanisms for sodium and water as seen in CHF, kidney failure, and liver failure.

Bibliography: Gulanick, Meg, PhD, RN, et.al (2003).Nursing Care Plan: Nursing Diagnosis & Interpretation. Westline Dive St. Louise. Mosby Inc. 5th ed, p. 65

At the end of 5 hours of nursing interventions, the patient will be able to stabilize fluid volume

as evidenced by:

a. Balanced intake and output;

b. Vitals signs within normal limits and;

c. Drain at least 1 liter of urine at foley catheter.

1. Assess for presence of edema by palpating over tibia, ankles, feet, and sacrum.® Pitting edema is manifested by a depression that remains after one’s finer is pressed over an edematous area and then removed.

2. Monitor daily weight of the patient.® Any change in weight is indicative of increase extracellular fluid volume.

3. Monitor VS of the patient. ® Tachycardia and increased blood pressure are seen in early stages. Elderly patients have reduced response to catecholamines, thus their response to fluid overload may be blunted, with less rise in heart rate.

4. Auscultate for a 3rd sound.® S3 sound is an early sign of pulmonary congestion.

5. Monitor for distended neck veins and ascites.® Distended neck veins mean increase pressure in the jugular veins brought about by increased circulating fluid.

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6. Monitor abdominal girth daily.

7. Monitor input an output® Although overall fluid intake may be adequate, shifting of fluid out of the intravascular to extravascular spaces may result in dehydration.

8. Evaluate urine output in response to diuretic therapy.® Focus on monitoring the response to the diuretics, rather than the actual amount voided. Fluid volume excess in the abdomen may interfere with the absorption of oral diuretic medications.

9. Check urinary catheter for presence of urine.® Treatment focuses on diuresis of excess fluid

10. Instruct patient regarding fluid restrictions as appropriate.® Facilitates reduction of extracellular volume.

11. Instruct patient to take diuretics as prescribed.® Diuretic therapy may include several different types of agents for optimal therapy, depending on the acuteness or chronicity of the problem.

12. Note medications that may cause fluid retention, such as non-steroidal anti-

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inflammatory agents, vasodilators, and steroids.

13. Instruct to avoid crossing of legs

® Reduce constriction of vessels thus preventing pooling.

14. Assist patient in repositioning every 2 hours® Prevent accumulation of fluid in dependent areas.

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