Assessment Explanation Planning Interventions Rationale Evaluation
Subjective: Renal disorder impairs Short Term: 1. Establish rapport 1. To assess precipitating Short Term:
“ I’m feeling weak and dizzy glomerular filtration that After 4-8 hours of nursing and causative factors. The patient shall have
and that I want to vomit but it resulted to fluid overload. interventions, patient will demonstrated behaviors to
won’t come out” With fluid volume excess, demonstrate behaviors to 2. To obtain baseline data monitor fluid status and
Objective: hydrostatic pressure is monitor fluid status and 2. Monitor and record vital reduce recurrence of fluid
pruritus higher than the usual reduce recurrence of fluid signs 3. To obtain baseline data excess
lethargic pushing excess fluids into excess
Lower extremity the interstitial spaces. Since 3. Assess possible risk
edema fluids are not reabsorbed at factors 4. To note for presence of
nausea the venous end, fluid Long Term: nausea and vomiting Long Term:
emesis volume overloads the lymph After 3 days of nursing The patient shall have
system and stays in the intervention the patient will 4. Monitor and record vital 5. To prevent fluid manifested stabilized fluid
VITAL SIGNS interstitial spaces leading manifest stabilize fluid signs. overload and monitor volume AEB balance I & O,
BP =180/110 mmHg the patient to have edema, volume AEB balance I & O, intake and output normal VS, stable weight,
PR = 80 beats/min weight gain, pulmonary normal VS, stable weight, and free from signs of
congestion and HPN at the and free from signs of 5. Assess patient’s appetite 6. To monitor fluid edema.
RR = 24 breaths/min
same time due to decrease edema. retention and evaluate
T = 36.5 Celsius
GFR, nephron degree of excess
hypertrophied leading to
decrease ability of the
kidney to concentrate urine 6. Note amount/rate of fluid 7. For presence of
Nursing Diagnosis
and impaired excretion of intake from all sources crackles or congestion
Fluid Volume Excess related
fluid thus leading to
to decrease of Glomerular
oliguria/anuria.
filtration Rate and sodium
7. Compare current weight 8. To evaluate degree of
retention
gain with admission or excess
previous stated weight
9. To determine fluid
8. Auscultate breath sounds retention
9. Record occurrence of 10. May indicate increase
dyspnea in fluid retention
11. May indicate cerebral
10. Note presence of edema. edema.
12. To evaluate degree of
11. Measure abdominal girth fluid excess.
for changes.
12. Evaluate mentation for 13. To prevent pressure
confusion and personality ulcers.
changes.
14. To monitor fluid and
electrolyte imbalances
13. Observe skin mucous
membrane. 15. To lessen fluid
retention and overload.
14. Change position of client
timely.
16. To monitor kidney
function and fluid
15. Review lab data like retention.
BUN, Creatinine, Serum
electrolyte. 17. Weight gain indicates
fluid retention or
edema.
16. Restrict sodium and fluid
intake if indicated 18. Weight gain may
indicate fluid retention
17. Record I&O accurately and edema.
and calculate fluid
volume balance
19. To conserve energy and
18. Weigh client lower tissue oxygen
demand.
20. To promote wellness.
19. Encourage quiet, restful
atmosphere.
20. Promote overall health
measure.
Assessment Explanation Planning Interventions Rationale Evaluation
Subjective: as alteration in the Short Term: 1. Ascertain attitudes of 1. Identifies areas to be Short Term:
Objective: epidermis and/or After 2-3 hours of nursing individual/SO(s) addressed in teaching After 2-3 hours of nursing
pruritus dermis. The skin is interventions, the client about condition. plan and potential interventions, the client
Lower extremity subject to injury from a will be able to: referral needs. (Nurses will be able to participate
edema variety of external and - tries to cooperate and pocket guide, 9thed, in prevention measures and
disruption of internal factors. participate in prevention Doenges, Moohouse, treatment programs
skin surface Extremes of heat and measures and treatment 2. Inspect skin in daily Murr, p.463)
VITAL SIGNS cold; pressure, program. basis, describing
BP =180/110 mmHg shearing, and other lesions and changes 2. To monitor progress of Long Term:
PR = 80 beats/min mechanical forces; Long Term: observed. wound healing The patient will no longer
RR = 24 breaths/min allergens; chemicals; After 8-12 hours of nursing have problems when it
T = 36.5 Celsius radiation; and interventions, the client 3. Keep the area comes to preventive
excretions and will be able to clean/dry, carefully 3. To assist body’s measure and treatment
secretions such as -do the preventive dress wounds, natural process of because of health education
those from an ostomy measures with assistance support incision repair and nursing care
Nursing Diagnosis or a draining wound and will be able to assistance.
Risk for Impaired Skin are all potentially understand why it is done
Integrity related to prolonged damaging conditions and what is reason for the 4. Use appropriate
immobility and substances that treatment program for the barrier dressing, 4. To protect wound and
exist in the external patient. wound coverings, surrounding tissue.
environment. Internal and skin-protective
factors include agents
emaciation, drugs, 5. Moisture potentiates
altered circulation and 5. Avoid use of plastic skin breakdow
impaired oxygen material and remove
transport, altered wet linens promptly 6. Promotes circulation
metabolic state, and and reduces risks
infections. associated with
immobility
6. Encourage early
ambulation 7. Enhances commitment
to plan, optimizing
outcomes
7. Assist the client/
SO(s) in
understanding; ff
medical regimen and
developing program 8. To assist in developing
of preventive care & plan of care for
daily maintenance problematic or
potentially serious
wounds
8. Consult with wound
specialist
9. Obtain specimen 9. To determine
from draining appropriate therapy
wounds when
appropriate for
culture sensitivities
and gram staining.
a. To control
10. Assist client to learn feelings of
stress reduction and helplessness
alternate therapy and deal with
techniques situation
