Cues:

SUBJECTIVE:
“Namamanas
ako at ang hina
ng katawan ko”
(I have edema and
I feel very weak)
as verbalized by
the patient
OBJECTIVE:
·Venous
distension
·Generalized
edema
·Patient
reports of
Fatigue,
weakness,
and malaise
·V/S taken as
follows
T: 35˚C
P: 50
R: 13
BP: 130/90

Diagnosis:
Fluid Volume
excess r/t
Compromised
regulatory
mechanism
(renal failure)
Renal failure
Decrease blood
flow to kidneys
Decrease
perfusion in
kidney
Decrease
urinary output
Water retention
Fluid volumes
Excess.
Objective of care
After 8 hours of
nursing
intervention, the
patient will
display
appropriate
urinary output
with specific
gravity/laborator
y studies near
normal; stable
weight, vital
signs within
patient’s normal
range; and
absence of
edema.
Interventions:
Independent
·Record accurate
intake and output
(I&O).
·Weigh daily at same
time of day, on same
scale, with same
equipment and
clothing
·Assess skin, face,
dependent areas for
edema
·Plan oral fluid
replacement with
patient, within
multiple restrictions
·Accurate I&O is
necessary for
determining renal
function and fluid
replacement needs
and reducing risk of
fluid overload
·Daily body weight is
best monitor of fluid
status
·Edema occurs
primarily in
dependent tissues
of the body, e.g.,
hands, feet,
lumbosacral area.
Patient can gain up
to 10 lb (4.5 kg) of
fluid before pitting
edema is detected
·Helps avoid periods
without fluids,
minimizes boredom
of limited choices,
and reduces sense
of deprivation and
evaluation:
Goal met,
patient has
displayed
appropriate
urinary output
with specific
gravity/laborato
ry studies near
normal; stable
weight, vital
signs within
patient’s
normal range;
and absence of
edema.