ASSESSMEN DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

T
SUBJECTIVE: Excess fluid syndrome is a After 8 hours INDEPENDENT: After 8 hours of
“Namamanas volume clinical disorder of nursing • Record • Accurate nursing
ang kanang related to of intervention accurate Intake interventions,
binti ng anak compromised unknown cause s, intake and and output is the patient was
ko” (My son regulatory characterized by the patient output of the necessary for able to display
has mechanism proteinuria, will patient. determining stable weight,
a massive with changes hypoalbuminemi display vital signs
renal function
edema
on his lower
in hydrostatic a stable and fluid within patient’s
right or oncotic , edema, and weight, vital replacement normal range,
leg) as vascular hyperlipidemia. signs within needs and and nearly
verbalized by pressure and This conditions patient’s reducing risk absence of
the mother. increased result from normal of edema.
OBJECTIVE: activation of excessive range, fluid overload.
• Edema the leakage of and nearly • Measures
• Weight gain renninangiotensi plasma proteins absence of the
• Changes in naldosterone into the urine edema. • Monitor urine kidney’s
vital signs system. because of specific gravity. ability
impairment of to concentrate
• V/S taken
the urine.
as follows:
glomerular • Daily body
T: 37.3
capillary weight is the
P: 85
membrane. best monitor
R: 21
• Weigh daily at of
same time of the fluid status. A
day, on same weight gain of
scale, with same more than 0.5
equipment and kg/day
clothing. suggest
fluid
retention.
• Edema
occurs
primarily in
dependent
tissues of the
Assess skin, body. It will
face, dependent serve as
areas of edema. parameter the
severity of
fluid
excess