Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective Data: Excess fluid volume Short term goal: Independent: Short term goal:
related to After 1 hour of 1. Establish rapport. 1. To gain the client’s After 1 hour of
Objective Data: compromised nursing intervention cooperation. nursing intervention
 Hematuria regulatory the client will be able the client was able to
 Proteinuri mechanism (AGN) to verbalize 2. Assess precipitating 2. To have a baseline verbalize
a as evidenced by understanding of factors: data. understanding of
 Edema of hematuria, individual dietary and a. Medical a. That can individual dietary and
both proteinuria, severe fluid restrictions. conditions contribute to fluid restrictions.
eyelids edema of both b. Determine excess fluid
and lower eyelids and lower Long term goal: amount of intake. Long term goal:
legs. legs, and blood After 3 days of fluid intake. b. Potential After 3 days of
 BP: 160/92 pressure level of nursing intervention c. Review exists for nursing intervention
mmHg 160/92 mmHg. the client will be able nutritional fluid overload the client was able
to: status. due to fluid to:
 Stabilize fluid shifts and  Stabilize fluid
volume as changes in volume as
evidence by electrolytes evidence by
balance input balance. balance input
and output, vital c. Imbalances in and output, vital
signs within these areas signs within
client’s normal are client’s normal
limit, stable associated limit, stable
weight, and free with fluid weight, and free
of signs of imbalances. of signs of
edema. edema.
 Demonstrate 3. Closely monitor vital 3. High blood pressure  Demonstrate
behaviors to signs every 4 hours, contributes to kidney behaviors to
monitor fluid especially the client’s damage. monitor fluid
status and blood pressure. status and
reduce reduce
recurrence of 4. Restrict fluid and 4. Restricting sodium recurrence of
fluid excess. sodium intake. favors renal excretion fluid excess.
of excess fluid and
may be more useful
than fluid restriction.

5. Calculate input and 5. So that adjustments

output accurately in can be made in the
24-hour fluid balance. following 24-hour
intake if needed.

6. Set an appropriate 6. To prevent

rate of fluid intake exacerbation of
throughout 24-hour excess fluid volume
period. and peaks and valleys
in fluid level.

7. Weigh daily and 7. This provides a

compare current comparative baseline
weight with admission and evaluates the
or previously stated effectiveness of
weight. diuretic therapy
when used.

8. Elevate edematous 8. To reduce tissue

extremities and pressure and risk of
change position skin breakdown.
frequently.

Dependent: 1. To reduce congestion

1. Administer and edema if heart
medications. failure is cause of
a. IV furosemide. fluid overload. Also,
b. Oral to treat high blood
amlodipine. pressure.