Nursing care plan 1.

Name of patient: Age/sex:

Ward: General ward : Medical Diagnosis

Nursing Diagnosis: Excess fluid volume related to fluid accumulation in tissue and third space
evidenced by edema.

S.N Assessment Nursing Nursing Plan of Rationale Nursing Evaluation

Diagnosis Goal action Intervention
1. Subjective Excess fluid Child will Measure It helps to find Abdominal Child
data:patient’s volume have no abdominal out the level of girth was maintains
uncle says, related to evidence of girth. distension. measured at fluid
“he has fluid fluid umbilicus volume
difficulty in accumulation accumulation Shift of fluid making with in
wearing in tissues and will Monitor the from the mark. normal
clothes due to and third maintain a common plasma to the limit as
swelling of spaces normal fluid sites of interstitial Edema has evidenced
legs. volume. edema. spaces been by absence
reduces the monitored. of edema
Objective vascular fluid and
data: volume. increase
patient has Monitor urinary
-mild Ascites Input/output It helps to output and
- lower chart. monitor fluid constant
extremities administration I/O charting weight and
swelling to prevent done by abdominal
-per orbital fluid overload. recording in girth.
edema Weight daily I/O form.
-Low urinary at same time Rapid wt.
output on same increase with
scale. associated
oliguria Patient’s wt.
indicates is taken daily
diminishing morning at
renal function. 10am.

Provide a Increase
non-added sodium will
salt diet. increase fluid
retention.
Administer
diuretics as Diuretics
prescribed. inhibit
reabsorption Food like
of sodium milk, egg and
from the loop low salt diet
of henle. has provided
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