PHINMA University of Pangasinan

College of Health Sciences

NURSING CARE PLAN

Patient’s Initials: M.Q.F. Chief Complaint: Stomach Ache Name of the Student Nurse: Abegail M. Quinto
Age & Gender: F & 49 years old Admitting Diagnosis: Hypervolemia Level/Block/Group: 2/13
Birthdate: 1.5. 1973 Clinical Instructor/s: Mrs. Angeli Garcia
Date of Confinement: December 15, 2022
Address: Date: December 15, 2022

NURSING ANALYSIS
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION

• Risk of impaired gas • Individual • Weight client • One kilogram of • Individual

weight gain is equal
exchange due to dietary and fluid daily. Observe for
Subjective: to one liter of fluid dietary and
insufficient fluid and restrictions will sudden weight retention (2.2
• “May kumikirot sa tyan ko at pounds). fluid
parang pagod na pagod ako’’ electrolyte intake or be verbalized by gain.
(There is a pain in my loss the patient. restrictions
stomach and I feel very tired)
• Edema can occur as
as verbalized by the patient. • Assess for
a result of or as a was verbalized
• Lack of knowledge in presence and result of a variety of
pathological by the patient.
assessing one's own location of edema
• The patient will conditions involving
hydration status formation. four competing • The patient
demonstrate forces: blood
Objective:
behaviors that hydrostatic and demonstrated
• Swelling in the feet
• Noncompliance due to osmotic pressures,
• Generalized weakness will allow him or as well as interstitial behaviors that
• Sudden weight gain insufficient information fluid hydrostatic and
her to monitor
• Shortness of breath about the need to osmotic pressures. allow him or
• Irritability fluid status and The dynamic
• Bounding pulses drink fluids, illness interaction of these
prevent or limit her to monitor
• VS Signs as follows: fatigue, and so on. four forces allows
BP – 120/70 recurrence. fluid to shift from fluid status and
CR - 61 one body
RR - 17 compartment to
T – 36.1 another. Edema in
dependent areas
• Poor community can be generalized prevent or limit
or localized. With
health as a result of a
relatively little recurrence.
lack of access to excess fluid, elderly
clients can develop
adequate nutrition dependent edema.
• Stable fluid
• Skin integrity is volume will be • Monitor intake • Reduced urinary
compromised due to demonstrated output and edema
and output. Note
formation may result
insufficient fluid intake by the patient, decreased urinary from decreased
and altered tissue as evidenced by renal perfusion,
output and
cardiac insufficiency,
perfusion. stable vital positive fluid and fluid shifts. • Stable fluid
signs, balanced balance on 24-
volume was
intake and hour calculations.
• Constipation risk output, stable demonstrated
associated with limited •
weight, and the Encourage • Fatigue and activity by the patient,
physical activity due to absence of intolerance result
adequate sleep.
from a lack of cardiac as evidenced
pain or weakness signs of edema. reserves. Rest,
caused by cardiac especially lying by stable vital
down, promotes
failure or diuresis and the signs,
hypoalbuminemia. reduction of edema.
balanced

• Infection risk as a intake and

result of lack of skin
turgor, dry mouth and output, stable
nasal passages,
lethargy, and sunken weight, and
eyeballs
the absence of

signs of

edema.
NURSING DIAGNOSIS

• Excess fluid volume due

to secondary to
hypervolemia as
evidenced by rapid
weight gain, dependent
edema, and shortness of
breath