Date Cues Nursing Diagnosis Needs Planning Implementation/Intervention Evaluation

& Goals/Objective
Time
SUBJECTIVE:“ Fluid Volume N After 8 hours 1. Established rapport. After 8 hours span of
S Maglisod ko ug excess r/t U of span of ® To gain trust & cooperation of patient. care, the patient had:
E ginhawa” as Compromised T care, the 2. Monitored vital signs.
P verbalized by regulatory R patient will: ® To monitor patient’s over-all status.  No urinary output
I
T the patient. mechanism 3. Record accurate intake and output because she has
T
E I  display (I&O). limited her oral fluid
M OBJECTIVE: O appropriat ® Accurate I&O is necessary for intake to almost not
B ® When patient has N e urinary determining renal function and fluid drinking unless thirsty
E  Venous renal failure, there is A output replacement needs and reducing risk of and she also has no
R distension decreased blood flow L  vital signs fluid overload. IVF.
 anasarca in the kidneys which - within 4. Weigh daily at same time of day, on  Vital signs are within
 orthopnea will decrease kidney M patient’s same scale, with same equipment and normal ranges.
3, tissue perfusion that E clothing.  Edema still present.
 oliguria normal
causes decreased T ® Daily body weight is best monitor of
 V/S taken A range;
as follows urine output and water  absence of fluid status.
B
2 will retain in the body. edema. 5. Assess skin, face, and dependent areas Goal Partially Met.
O
-T: 36.0˚C L for edema.
0 Bibliography: I ® Edema occurs primarily in dependent
-P: 65
-R: 18 Doenges, Marilyn et. C tissues of the body, e.g., hands, feet,
1 Al.2008. Nurse’s lumbosacral area.
-BP: 120/80
Pocket Guide.F.A. P 6. Limit fluids as indicated.
0 Davis Company A ® Fluid management is usually calculated
T to replace output from all sources plus
@ T
estimated insensible losses
E
R 7. Administer medications as indicated.
11pm ®Given early in oliguric phase of Renal
N
Failure in effort to convert nonoliguric
phase, flush the tubular lumen of debris,
reduce hyperkalemia, and promote
adequate urine volume.