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Fluid Volume Excess related to Disease Process

ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Fluid Volume Excess Short Term: Dependent: Short Term:
“Napansin kong sumikip related to Disease Process: After 8 hours of  Restrict sodium and  To minimize the risk of After 8 hours of
ang relo niya dahil sa compromised renal nursing fluid intake to equal pulmonary edema, hypertension, nursing intervention
manas.” as verbalized by perfusion intervention the urinary and insensible and cardiac failure. the client’s edema
the Mother client will be able loss was rediced from
Inference: to reduce edema  Administered  These controls hypertension Grade 4+ to Grade 2+
Increased isotonic fluid from Grade 4+ to antihypertensives and and fluid volume
Objective: retention. Acute Grade 1+ in cases, loop diuretics
 General Glomerulonephiritis is an such as furesimide
Appearance: acute inflammation of (Lasix) and bumetanide Long Term:
-Generalized Edema= glomeruli within the Long Term: (Bumex) as ordered After 3 days of nursing
Grade 4+ kidney. Membrane After 3 days of intervention the client
-Weak in appearance permeability is altered by nursing Independent: exhibited no signs of
-irritable immune response,thus intervention the 1. Evaluated extent of fluid compromised renal
allowing protein to leak client will be able excess: perfusion as
Vital signs: into the urine. Sodium is to exhibit no  Weighed the client daily  Rapid increase in weight with evidenced by normal
-BP= 120/90 mmhg retained within the serum signs of associated oliguria indicates urinary output and no
(moderate and water follows a compromised diminishing renal function. edema as evidenced
hypertension) decrease in the plasma renal perfusion  Obtain baseline for by:
 Assessed vital signs: BP, PR,
-RR=33 bpm filtration. The comparison. Objective and
RR, quality of pulse,
-PR=108 bpm accumulation of water and subjective data help identify U.O.= 30 ml/hour
respiratory effort, and
-Tempearature=39.5 c sodium leads underlying cause and monitor With good skin
weight.
progress.Changes In pulse and integrity
 Physical respiration may indicate cardiac
Assessment: decompression.
-pale
-distended abdomen Reference:  Provide Meticulous skin
 To prevent further damage
-weight=18 kilograms Nurses Pocket Guide by care
the skin
-Oliguria=15 ml/hour Doenges,
Moorhouse,Murr 11th  Noted complaints
 To monitor the degree of
Edition pg. 327-330 associated with fluid excess:
edema and monitor the progress.
edema, poor skin turgor,
Pediatric Nursing by Potts distention of neck veins,
and Mandleco Thomson sudden increase in weight.
 Laboratory Result: Asian Edition Copyright
-urinalysis= revealed 2002  Suggested interventions  To reduce discomfort of fluid
proteinuria and such as oral care, chewing restriction
hematuria gum/hard candies and used
- hematorcit=30 of lip balm
-hemoglobin=98
2.Limited sodium and fluid
intake to prescribed value:

Advised family members to  Fluid restriction is based on urine

remove water, food or output, weight and response to
drinks from bedside. therapy and To monitor other
sources of excess fluid

Identified potential sources Understanding and comfort

of fluid (IV and oral meds, promotes compliance.
food, etc), and factor them
in when determining fluid  Prevent fluid
intake. overload and address causative
factors.
Elevate edematous
extremities.Change position  To reduce tissue pressure
frequently.

2. Assisted client and family to  To provide comfort and offer

cope with the discomfort reassurance.
caused by fluid restrictions:  For compliance to treatment
 Explained the rationale and provide appropriate
behind fluid restriction. information.
 The family can help for the
 Encouraged the family to fast recovery of the patient.
provide a supportive and
caring atmosphere

Collaborative:

 Arranged dietary  To promote proper nutrition

consultation for menu
 planning
 To monitor abnormalities:
 Evaluated laboratory Urinalysis reaveals increased specific
results: gravity; serum
urinalysis,serum electrolyte,BUN,creatinine
eletrolytes,BUN, abnormalities reflect altered renal
Creatinine, erythrocyte function; ESRreflects inflammation
sedimentation and ASO titer detect streptoccal
rate,antistreptolysin antibodies.
O titer

Refference:Nurses Pocket
Guide by Doenges,
Moorhouse,Murr 11th Edition
pg. 327-330

3. Impaired Urinary Elimination related to Disease Process

4. Hyperthermia related to Disease Process