NURSING CARE PLAN #

ASSESSMENT

DIAGNOSIS
(NANDABASED)

PLANNING

IMPLEMENTATION

Independent:
Subjective:
Galisod siya ug
ginhawa, as
verbalized by the
patients sister.

Objective:
- (+) weight gain
- (+) edema
- (+) ascites
- (+)
hepatomegaly
- (+) crackles
- Shortness of
breath

Excess Fluid
Volume r/t
sodium and
water retention

Short Term:
After 45 minutes of
nursing
interventions, patient
will be able to:
1. Verbalize
understanding
of individual
dietary and fluid
restrictions.
2. Demonstrate
behaviors to
monitor fluid
status and
reduce
recurrence of
fluid excess.

Long Term:

1. Record intake and output.

2. Weigh patient daily at the
same time each day.
3. Measure vital signs and
invasive hemodynamic
parameters.
4. Record occurrence of
exertional breathlessness,
dyspnea at rest, or
paroxysmal nocturnal
dyspnea.
5. Note presence of edema.
6. Measure abdominal girth.
7. Provide for sodium
restrictions if needed.
8. Elevate edematous
extremities, change
position frequently.
9. Place in semi-Fowlers
position, as appropriate.
10. Promote early
ambulation.
11. Observe skin and mucus
membranes.

After 1-2 weeks of

nursing interventions
Collaborative/Dependent
the patient will be
:
able to :
12. Administer diuretics as
1. Stabilize fluid

RATIONALE

1. Accurate intake and

output is necessary
for determining renal
function and fluid
replacement needs
and reducing risk of
fluid overload.
2. Daily body weight
is best monitor of fluid
status.
3. Blood pressure may
be high because of
excess fluid volume
or low if cardiac
failure is occurring.
4. Indication of
pulmonary congestion
and potential of
developing pulmonary
edema that can
interfere with oxygen
carbon dioxide
exchange at the
capillary level.
5. Heart failure and
renal failure are
associated with
dependent edema

EVALUATION
(ACTUAL)

Short Term:
Goals met.
Patient was able
to understand
how to lessen
fluid volume
excess by
reducing salt
intake, elevating
the edematous
part of the body
above the level
of the heart and
importance of
taking antihypertensive and
diuretics.

Long Term:
Goals partially
met. By
September 1,

volume as
evidenced by
balanced input
and output
(I&O), vital
signs within
clients normal
limits, stable
weight, and free
of signs of
edema

ordered.
13. Administer antihypertensives as ordered.

because of
hydrostatic pressures,
with dependent
edema being a
defining characteristic
for excess fluid.
6. Change may indicate
increasing fluid
retention/edema.
7. Restricting sodium
favors renal excretion
of excess fluid and
may be more useful
than fluid restriction.
8. To reduce tissue
pressure and risk of
skin breakdown.
9. To facilitate
movement of
diaphragm, thus
improving respiratory
effort.
10. To reduce tissue
pressure and risk of
skin breakdown.
11. For presence of
decubitus or
ulceration.
12. To excrete excess
fluids.
13. To treat hypertension
by counteracting
effects of decreased
renal blood flow and

2016, patient no
longer had leg
edema after
following
appropriate diet
and measures on
how to reduce
edema and
compliance of
medication.
However, vital
signs are still not
stable,
specifically
respiratory rate
and pulse rate.

circulating volume
overload.