Date: July 11, 2011

Nursing Intervention /
Cues Patient’s Analysis of Implementation Rationale of
Subjective/ problem/ patient’s Objective Nursing Nursing Order Intervention Evaluation
Objective Nursing problem Actions
Diagnosis

Objective: Fluid volume There’s an  After 2-3hours > To evaluate >Evaluate mentation >For confusion or Goal was met
>Edema, grading excess related increase fluid of nursing degree of excess personality after 2-3 hours
edema of 2+ retention interventions changes of nursing
disappears 10-15
to an amount or patient will be interventions
secs. compromised quantity of fluid able to patient was able
regulatory beyond what is verbalize verbalized
Subjectives: mechanism as normal or understanding > To Promote >Restrict Na and > To emphasize understanding
>Restlessness evidenced by sufficient to our of individual mobilization/elimi fluid intake dietary/fluid of individual
>wt: 145lbs body. dietary/fluid nation of excess restriction dietary/fluid
tissue edema restrictions fluid restriction.

>Advised to elevate > To reduce

the edematous tissue pressure
extremities, change and risk for skin
position frequently breakdown

> To promote >Stress the need for >To prevent stasis

wellness mobility and and risk of tissue
frequent position injury
changes

>Identify signs >To ensure timely

requiring evaluation/interv
notification of ention
healthcare provider