Nursing Care Plan

Date Cues Need Nursing Diagnosis Patient Outcome Nursing Interventions Implementation Evaluation
9/29/2 Subjective cues: N Excess fluid volume After 8 hours of - Monitor and record 1
1 - “Sa U related to sodium interventions, patient vital signs
nakaraang T retention as evidenced will verbalize R: The client’s blood
araw masakit R by presence of edema understanding of the pressure and heart
ang ulo at I and blood pressure of measures to prevent rate may indicate
nasusuka T 160/100 mmHg. and lessen excess fluid fluid volume. It will
ako” I volume to normalize also help in the
- “Namaga O - R: Fluid Volume sodium level and blood evaluation of
ang paa at N Excess (FVE), or pressure. progress from
binti ko” A hypervolemia, treatment.
As verbalized L refers to the
by the client excessive - Start patient on a 2
as well as; M accumulation of strict fluid balance
- Shortness of E fluid in the chart.
breath, chest T extracellular fluid R: A record of the
pain A compartment patient’s fluid intake
- Reduced B (ECF) and is and output will help
urine O mainly associated identify the main
frequency L with sodium source of fluid
I regulation. excess. It will also
Objective cues: C Excessive intake help the staff and
- Edema of sodium from patient if the fluid
(lower foods may cause output is enough in
extremities) FVE (as comparison to fluid
- Temp: evidenced by intake.
afebrile edema) and
- PR: 90 bpm can also increase - Discuss the following
- BP: 160/100 blood pressure measures to prevent
mmHg which may cause and lessen fluid
 long-term volume excess: 3
cardiovascular A.) Advise
risk and patient to
complications elevate feet
during pregnancy. when sitting
down.
https://www.freseniuskid R: This
neycare.com/thrive- prevents and
central/hypervolemia lessens fluid
accumulation
in lower
extremities.
B.) Instruct 4
patient
regarding
restricting
fluid intake.
R: Intake of
fluid up to 500
ml is
equivalent to
0.5kg.
Increase in
weight due to
fluid retention.
Therefore
limiting is
necessary to
avoid fluid
retention.
C.) Instruct 5
patient,
caregiver,
 and family
members
regarding
fluid
restrictions,
as
appropriate.
R: Information
and
knowledge
about
condition are
vital to
patients who
will be co-
managing
fluids.
D.) Limit sodium 6
intake as
prescribed.
R: Restriction
of sodium aids
in decreasing
fluid retention
E.) Monitor fluid 7
intake.
R: This
enhances
compliance
with the
regimen.
8
- Explain possible
 causes of fluid
volume excess.
R: Fluid balance can
be affected by
several factors such
as high oral fluid
intake, water-rich
fruits, salty foods and
electrolyte
imbalance. 9

- Monitor
patient’s
electrolyte
levels,
particularly the
serum sodium
levels
R: Sodium is a
major
extracellular fluid 10
electrolyte partly
responsible for
fluid balance.

- Administer
medications as
prescribed
(diuretics or
antihypertensive).
R: Diuretics help in
the excretion of 11
excess fluid build-up.
 Antihypertensive
helps to lower blood
pressure.

- Review intravenous
fluid orders.
R: Most intravenous
fluids contain sodium
which can affect fluid
balance.