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    Nursing Care Plan: Problem

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    Marius Clifford Billedo
    The nursing care plan assessed a patient experiencing fluid volume excess, renal failure, and activity intolerance based on subjective reports of weakness and objective findings of edema and fatigue, with goals of decreasing fluid retention and increasing activity tolerance through interventions like monitoring intake/output, administering diuretics and antihypertensives, assessing ability to perform activities of daily living, and providing rest. Evaluation found the goals were met as the patient displayed appropriate urinary output and vital signs, absence of edema, and increased activity tolerance.

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    Nursing Care Plan: Problem

    Uploaded by

    Marius Clifford Billedo
    85 views4 pages
    The nursing care plan assessed a patient experiencing fluid volume excess, renal failure, and activity intolerance based on subjective reports of weakness and objective findings of edema and fatigue, with goals of decreasing fluid retention and increasing activity tolerance through interventions like monitoring intake/output, administering diuretics and antihypertensives, assessing ability to perform activities of daily living, and providing rest. Evaluation found the goals were met as the patient displayed appropriate urinary output and vital signs, absence of edema, and increased activity tolerance.

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    ncp

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    NCP final

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    The nursing care plan assessed a patient experiencing fluid volume excess, renal failure, and activity intolerance based on subjective reports of weakness and objective findings of edema and fatigue, with goals of decreasing fluid retention and increasing activity tolerance through interventions like monitoring intake/output, administering diuretics and antihypertensives, assessing ability to perform activities of daily living, and providing rest. Evaluation found the goals were met as the patient displayed appropriate urinary output and vital signs, absence of edema, and increased activity tolerance.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    85 views4 pages

    Nursing Care Plan: Problem

    Uploaded by

    Marius Clifford Billedo
    The nursing care plan assessed a patient experiencing fluid volume excess, renal failure, and activity intolerance based on subjective reports of weakness and objective findings of edema and fatigue, with goals of decreasing fluid retention and increasing activity tolerance through interventions like monitoring intake/output, administering diuretics and antihypertensives, assessing ability to perform activities of daily living, and providing rest. Evaluation found the goals were met as the patient displayed appropriate urinary output and vital signs, absence of edema, and increased activity tolerance.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4

    NURSING CARE PLAN

    ASSESSMENT
    Subjective:
    lumlumbeg toi bagbagik aglalo toi makin
    kannawan nga imak
    ken agkakapsot nak
    , as verbalized by the
    patient
    Objective:
    Venous
    distension
    Generalized
    edema
    Patient reports
    of Fatigue,
    headache
    weakness,and
    malaise

    NURSING
    DIAGNOSIS

    SCIENTIFIC
    BACKGROUND

    GOAL/OBJECTIVE
    Date: june 16, 2012
    Time: 7:00 am

    Problem:
    Fluid Volume excess
    Renal failure

    Etiology:
    Related to
    compromised
    regulatory
    mechanism(renal
    failure)
    Sign/ Symtoms:
    Generalized
    edema
    Body
    weakness
    Headache
    Weak looking
    Fatigue

    Goal/ Objective:
    Decrease blood
    flow to kidneys

    Decrease
    perfusion in
    kidney

    After shift
    The patient will
    display appropriate
    urinary output with
    specific
    gravity/laboratory
    studies near normal
    stable weight

    Decrease urinary
    output

    vital signs
    within
    patients
    normal range

    Water retention
    V/S taken as
    follows:
    T: 36.7 C
    RR: 16 cpm
    PR: 59 bpm
    BP: 130/90

    absence of
    edema
    Fluid volume
    excess

    NURSING INTERVENTION

    RATIONALE

    Independent:
    Record accurate
    intake and
    output(I&O).
    Weigh daily at
    same time of day,
    on same scale, with
    same equipment
    and clothing
    Assess skin, face,
    dependent areas
    for edema
    Plan oral fluid
    replacement with
    patient, with in
    multiple
    restrictions
    Dependent:
    Administer/restrict
    fluids as indicated.
    Administer
    medication as

    Accurate I&O is
    necessary for
    determining renal
    function and fluid
    replacement need
    sand reducing risk of
    fluid overload
    Daily bodyweight is
    best monitor of
    fluid status

    Edema occurs
    primarily
    independent
    tissues of the body,
    e.g., hands, feet,
    lumbosacral area.
    Patient can gain up
    to 10 lb (4.5 kg) of
    fluid before pitting
    edema is detected
    Helps avoid periods
    without fluids,
    minimizes
    boredom of limited

    EVALUATION
    Date: June 16, 201`2
    Time:4:00 pm
    Level of attainment:
    Goal met, patient
    has displayed
    appropriate urinary
    output with specific
    gravity/laboratory
    studies near normal;
    stable weight, vital
    signs with in
    patients normal
    range; and absence
    of body weakness
    and malaise.

    15

    indicated Diuretics,
    e.g., furosemide
    (Lasix),mannitol
    (Osmitrol)
    Antihypertensive,
    e.g., clonidine
    (Catapres)

    choices, and
    reduces sense of
    deprivation and
    thirst

    Fluid management
    is usually
    calculated to
    replace output
    from all sources
    plus estimated
    insensible losses
    Given early in
    oliguric phase of
    Renal Failure in an
    effort to convert
    on oliguric phase,
    flush the tubular
    lumen of debris,
    reduce hyper
    kalaemia, and
    promote adequate
    urine volume

    16

    NURSING CARE PLAN


    ASSESSMENT

    Subjective:
    agkakaps
    ot nak nga
    kanaun
    nadaras
    nak pay
    nga
    mabannog
    as
    verbalized
    by the
    patient.

    Objective:
    Fatigue.
    Greater
    needfor
    sleep and
    rest.
    Body
    weakness
    V/S taken
    asfollows:
    T: 36.7 C
    RR: 16 cpm
    PR: 59 bpm

    NURSING
    DIAGNOSIS

    Problem:
    Activity
    intolerance

    Etiology:
    Related to
    imbalance
    between oxygen
    supply (delivery)
    and demand.

    SCIENTIFIC
    BACKGROUND

    GOAL/OBJECTIVE
    Date: june 16, 2012
    Time: 7:00 am
    Goal:After the
    patient will:
    Report
    anincrease
    inactivity
    toleranceincl
    udingactivitie
    s of
    dailyliving.
    Demonstrate
    a decrease in
    physiological
    signs of
    Intolerance.
    Display
    within
    acceptable
    range.
    Long term:
    After months
    nursing
    interventions
    ,the patient:
    Is free form
    weakness

    NURSING INTERVENTION

    RATIONALE

    Independent:
    Assess
    patientsability to
    performnormal task
    oractivities of
    dailyliving.
    Note changes
    inbalance/
    gaitdisturbance,
    muscle weakness.
    Recommend
    quietatmosphere,
    bed restif indicated.
    Elevate the head
    ofthe bed as
    tolerated.
    Provide or
    recommend
    assistance with
    activities or
    ambulation as
    necessary, allowing
    patient to do as
    much as possible.

    influences choice of
    interventions or needed
    assistance
    May indicate
    neurological changes
    associated with vitamin
    B12 deficiency, affecting
    patient safety or risk of
    injury.
    Enhances rest tol ower
    bodys oxygen
    requirements, and
    reduces strain on the
    heart and lungs.

    EVALUATION
    Date:june 16, 2012
    Time: 3:00 pm
    Level of
    attainment: GOAL
    MET
    Evidences:
    The significant
    others was able:
    To
    enumerate
    techniques
    to prevent
    aspiration.
    To identify
    risk factors.

    Enhances lung expansion


    to maximize oxygenation
    forc ellular up take.
    Although help maybe
    necessary, selfesteem is
    enhanced when patient
    does some things for self.

    Promotes gradual return


    to normal activity level
    and improved muscle
    17

    BP: 130/90

    and risk for


    complicatio
    ns hasbeen
    prevented.

    Plan activity
    progression with
    patient, including
    activities that the
    patient views
    essential. Increase
    levels of activities
    as tolerated.

    Encourages patient to
    do as much as possible,
    while conserving limited
    energy and preventing
    fatigue.

    Identify or
    implement energy
    saving technique
    like sitting while
    doing a task.

    Identifies deficiencies in
    RBC components
    affecting oxygen
    transport and treatment
    needs or response to
    therapy.

    tone or stamina without


    undue fatigue.

    Collaborative:
    Monitor laboratory
    studies. Hct and
    RBC count, arterial
    blood gases
    (ABGs).

    18

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