Assessment
Establish rapport
Subjective data:
“Namamanas yung binti ko,
hindi ko alam bakit ngkaganito”
as verbalized by the patient.
Objective data:
 Left leg edema
 BP 170/140 mmhg
 Jugular vein distention
 Frequent yawning
 Height: 5'10"
 lbs to 243 lbs.
Weight 257 lbs
Diagnosis Goal Intervention Evaluation
To gain patient’s trust and
After health cooperation.
teaching the patient
will be able to Monitor and record vital
demonstrate signs To assess precipitating and
Fluid Volume Excess behaviors to causative factors. Also as baseline The patient was able to
related to decrease data. recognize foods to
monitor fluid status restrict to avoid further
glomerular filtration and reduce damage to the kidneys.
rate and sodium Auscultate breath sounds
recurrence of fluid
retention For presence of crackles or
excess congestion
Note presence of edema. The patient’s weight has
Patient will manifest To determine fluid been reduced from 257
stabilize fluid retention.
volume AEB balance
I&O, normal VS, Measure abdominal girth
stable weight, and for changes. May indicate
increase in fluid retention
free from signs of
edema. Take Prescribed medication by
the Physician.
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Change position of client
timely to prevent pressure injury

Review lab data like

BUN, Creatinine, Serum
electrolyte.
To monitor fluid and electrolyte
imbalances

Educate patient what

foods to restrict to lessen
fluid retention and overload.

Record I&O accurately

and calculate fluid
volume balance
To monitor kidney function and
fluid retention

Weigh client
Weight gain indicates fluid
retention or edema.

Encourage quiet, restful

atmosphere. To conserve
energy and lower tissue oxygen
demand.

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Assessment Diagnosis Goal Intervention Evaluation

Assess the extent of

weakness, fatigue,
Subjective data:
The patient will be able to
ability to participate in
“nahihirapan ako Activity recognize and avoid active and passive After Nursing
huminga, naglakad lng Intolerance activities and situation that activities. intervention, we will
nmn ako para sunduin related to might cause him fatigue Provides information about be able to determine
anak ko sa school” as Insufficient . the impact of activities on through laboratories
verbalized by the patient. physiologic or that deficiency in
fatigue and energy reserves. blood components
physiological After Nursing intervention affects Patients
Objective Data: energy to endure and health teaching the Encourage quiet activity tolerance.
or complete patient will be able to
environment during times
pale skin required or tolerate simple activities In addition, after
that does not require too of fatigue to promote nursing intervention
shortness of breath desired activity
rapid heartbeat Possibly evidenced much energy. relaxation. the patient will be
dizziness able to tolerate
by Reports of
activities while
fatigue on exertion pausing and giving self
Collaborative: rest periods during
Monitor Laboratory activities.
studies. HB or Hct and
RBC count, arterial blood
gasses (ABGs)
To identify deficiencies in
RNB components affecting
oxygen transport and
treatment needs or
response to therapy.

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Assessment Diagnosis Goal Intervention Evaluation
Provide Oxygent o the
Knowledge, deficient patient.
After Nursing To relieve any difficulty
Subjective data regarding condition,
intervention, the with breathing
treatment plan and patient will be able to After Nursing
“Nurse, ang sakit ng initiative necessary intervention, the patient
Monitor vitals
dibdib ko. Nahihirapan lifestyle changes lifestyle changes and *Maintain reasonable was able to verbalize and
ako huminga kahit wala participate in the blood pressure to help show medication
ako ginagawang Possibly evidenced treatment regimen. protect the kidneys from compliance to lower his
mabibigat na gawain” as further damage blood pressure.
verbalized by the patient. by Verbalization of
Also the patient will
be able to maintain Assess
the problem
Objective data: Blood pressure within cardiopulmonary After nursing
normal range. system: Auscultate intervention, the patient
Blood Pressure: heart and lungs for was able to verbalize
170/120mmhp abnormal sounds relief from difficulty with
breathing.
Irregular heartbeat. *Fluid retention from
Difficulty breathing. improper glomerular
Monitor vitals filtration may collect in
the myocardium resulting
in stress on the heart and
Cool clammy skin in the lungs. Listen for
friction rub and
pulmonary crackles or
congestion

Monitor I & O
*Monitor kidney function
and calculate fluid
retention.

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Daily weights at the
same time each day on
the same scale can also
help determine amount
of fluid being retained.

Palpate abdomen
To assess for fluid
retention

Restrict fluids
*Closely monitor fluid
intake to prevent
overload and help reduce
retention and promote
emptying of the bladder

Nutrition education
A renal diet is low in
protein and sodium. The
kidneys are
compromised and unable
to remove the waste
produced by processing
proteins (BUN)

Choose foods low in

saturated and trans fat to
prevent and lower fat
deposits in the blood
vessels.

Choose lower potassium

foods to avoid
hyperkalemia caused by
excess potassium
retention.

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Take prescibbed
medications by the
physician.

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