ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTION EVALUATION

Subjective: “May Fluid volume Short term: INDEPENDENT After 1 hour of

mga manas ako sa excess related At the end of 2 >Explain the nursing intervention,
kamay at paa to fluid shift hours nursing importance of close the client verbalizes
mula nang mag from intervention, monitoring of weight, understanding of need
anim na buwan intracellular to the client will vital signs, I/O, for close monitoring
ang tiyan ko” as extracellular be able to urine protein and of weight, BP, urine
stated by the fluid as understand the edema. protein, and edema and
client. evidenced by need for close Rationale: So the engages in therapeutic
edema formation monitoring of client will become regimen and
weight, blood aware of her monitoring.
Objective: pressure, urine condition
Presence of protein and
edema in face edema and >Weigh patien.t After 3 days of
and upper and engages in regularly. Tell nursing intervention,
lower therapeutic client to record the client is free of
extremities regimen and weight at home in signs of generalized
monitoring as between visits. edema
Shiny, cold and indicated. Rationale: To
clammy skin identify if there is
Long term: an increase in fluid
Presence of After 3 days of retention
protein in the nursing
urine (2/20/19) intervention, >Monitor Vital signs
the client has Rationale: to
stabilized fluid determine the
BP: 200/140 volume as client’s
T: 37.0 °c evidenced by physiological state
PR: 85 bpm balanced I/O, DEPENDENT
RR: 20 cpm vital signs > Differentiate
within client’s physiological and
weight: 81kg normal limits, pathological edema of
Stable weight pregnancy. Locate and
and free of determine degree of
signs of edema. pitting.
Rationale: To define
characteristic of
excess fluid.

COLLABORATIVE
> Check on dietary
intake of proteins
and calories. Give
information as
needed.
Rationale: To
determine imbalances
in these areas that
are associated with
fluid imbalances

> Monitor intake and

output. Note urine
color, and measure
specific gravity as
indicated.
Rationale: To ensure
accurate picture of
fluid status

> Assess lung sounds

and respiratory
rate/effort.
Rationale: To assess
if there is a
pulmonary edema

>Administer
medications as
ordered
Rationale: To
identify medications
that can alter fluid
and electrolyte
balance.