DAVAO DOCTORS COLLEGE

General Malvar St., Davao City

Nursing Program
NURSING CARE PLAN
Name of Patient: Patient R.M Date of Admission: September 12, 2022 Room: 143
Age: 55 years old Sex: Male Civil Status: Married Chief Complaint: deep, rapid, shallow breathing, mental delirium and confusion
Religion: N/A Attending Physician: Dr. Beng Gow

DATE & CUES NURSING DIAGNOSIS GOALS & NURSING INTERVENTIONS RATIONALE EVALUATION
TIME OBJECTIVES
September Subjective: Nsg Dx: After 3 days of September 15, 2021
12, 2022 “Natingala ko ana niya nursing 1. Obtain a patient 1. History may include
sir na ning kalit raman Excess fluid volume interventions, the history to ascertain increased fluids or GOALS MET
siyag kahupong. Dili related to patient will be able the probable cause sodium intake,
ganahan muhigda kay compromised renal to: of the fluid medical conditions After 3 days of
punga na daw kaayo. regulatory disturbance. that cause the nursing interventions
Ang iyahang singsing abnormal retention of the patient was able
mechanisms as
guot na. Ang iyahang a. Show signs of a fluids (e.g., renal to:
medyas og sapatos evidenced by reduced abdominal failure), or h=shifts
dili na kasigo”, as glomerular filtration girth less than 40 between the
verbalized by the rate inches interstitial space and h. Show signs of a
patient’s wife. b. Show signs of plasma, reduced abdominal
reduction of edema girth that measured
His wife said that one with bipedal grade of 2. Monitor for a 2. Body weight is more 38 inches.
month prior to Rationale/Scientific 0-2mm. significant weight sensitive indicator of i. Show signs of
admission, the patient Basis: c. Have a normal change (2 pounds fluid or sodium reduction of edema
had difficulty sleeping Renal disorder heart rate between in 1 day). retention than intake with bipedal grade of
and had started to use impairs glomerular 60-100bpm. and output. A 2-3 1 mm.
2 pillows to support his filtration that resulted d. Have a normal pounds increase in j. Have a normal
back when lying down to fluid overload. With blood pressure weight normally heart rate of 85bpm.
because he cannot fluid volume excess, between 120/80- indicates a need to k. Have a normal
breathe properly. hydrostatic pressure 90/60 mmHg. adjust fluid or diuretic blood pressure
is higher than the e. Show no signs of therapy; 2.2 pounds 120/80mmHg.
Objective: usual pushing excess pulmonary rales and (1kg) is equivalent to l. Show no signs of
- PR: 108 bpm fluids into the crackles upon 1L fluid. pulmonary rales and
-BP: 180/100 mmHg interstitial spaces. auscultation. crackles upon
- (+) rales and Since fluids are not f. Have an improved 3. Monitor input and 3. Although overall fluid auscultation.
crackles reabsorbed at the mental status by output closely. intake may be m. Verbalize the
- (+) Bipedal edema venous end, fluid being oriented to adequate, shifting of correct time, person,
grade 4 volume overloads the time, person, and fluid out of the and place.
- (+) periorbital edema lymph system and place. intravascular to the n. Show no signs of
- (+) abdominal stays in the interstitial g. Show no signs of extravascular spaces orthopnea or
distention with spider spaces leading the orthopnea or may result in dyspnea when lying
web-like veins patient to have dyspnea. dehydration. down or changing
appearance edema, weight gain, positions.
 DAVAO DOCTORS COLLEGE
General Malvar St., Davao City
Nursing Program
NURSING CARE PLAN
-Abdominal girth: 48 pulmonary congestion 4. Evaluate weight in 4. In some patients with
inches and HPN at the same relation to heart failure, weight
-GFR: 15ml/min time due to decrease nutritional status. may be a poor
GFR, nephron indicator of fluid
hypertrophied leading volume status. Poor
to decrease ability of nutrition and
the kidney to decreased appetite
concentrate urine and over time result in a
impaired excretion of decrease in weight,
fluid thus leading to which may be
oliguria/anuria. accompanied by fluid
retention even though
REFERENCE: the net weight
Gulanick, M., & remains unchanged.
Myers, J.L. (2017).
Nursing care plans: 5. If the patient is on 5. Patient should be
Diagnoses, fluid restriction. reminded to include
interventions, and terms that are liquid
outcomes. Elsevier at room temperature
Health Sciences. such as gelatin,
sherbet, soup and
frozen juice pops.

6. Monitor BP and 6. Sinus tachycardia

HR. and increased BP are
seen in early stages.
Older patients have a
reduced response to
catecholamines; thus
their response to fluid
overload may be
blunted, with less
increase in HR.

7. Have a patient sit 7. This position

up if he reports promotes pooling of
shortness of fluid in the lung bases
breath. and makes more lung
tissue available for
gas exchange.
DAVAO DOCTORS COLLEGE
General Malvar St., Davao City
Nursing Program
NURSING CARE PLAN

8. Advise the patient 8. This position reduces

to elevate his feet edema in the lower
when sitting down. extremities and
increase venous
return.

9. Instruct patient 9. Sodium intake

regarding produces a feeling of
restricting dietary thirst. By restricting
sodium. sodium intake, the
amount of fluid a
patient drinks can be
reduced.

10. Instruct patient in 10. Maintaining fluid

the administration balance is improved
of anti-hypertensive by the control of BP
medication such as to preserve remaining
Captopril 25mg/tab nephron function and
PO OD as per slow the progression
doctor’s order. of CKD.

11. Administer diuretic 11. Diuretics are mainly

such as used in patients with
Furosemide chronic kidney
40mg/amp, 1 amp disease (CKD) for the
IVTT as per treatment of edema,
doctor’s order. to assist in reducing
blood pressure and to
aid in lowering serum
levels of K+ in patient
with hyperkalemia (a
secondary feature of
their action).

12. Teach causes of 12. Information is key to

fluid volume excess managing problems.
to the patient.
DAVAO DOCTORS COLLEGE
General Malvar St., Davao City
Nursing Program
NURSING CARE PLAN
13. Explain the 13. Knowledge enhances
importance of compliance with the
maintaining proper treatment plan.
nutrition, hydration,
and diet
modifications.

NAME OF STUDENT