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    Nursing Care Plan For Patient With Excessive Fluid

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    Tsaabitah Anwar
    Mr. F is a 56-year-old man with CKD stage V who presented with shortness of breath. Lab results showed azotemia, decreased hematocrit and hemoglobin, and electrolyte imbalance. He has pitting edema and does not want regular dialysis due to concerns about his business income. The nursing care plan involves assessing fluid status, limiting fluid intake, identifying fluid sources, and explaining the rationale for restriction to promote compliance and comfort.

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    Nursing Care Plan For Patient With Excessive Fluid

    Uploaded by

    Tsaabitah Anwar
    111 views11 pages
    Mr. F is a 56-year-old man with CKD stage V who presented with shortness of breath. Lab results showed azotemia, decreased hematocrit and hemoglobin, and electrolyte imbalance. He has pitting edema and does not want regular dialysis due to concerns about his business income. The nursing care plan involves assessing fluid status, limiting fluid intake, identifying fluid sources, and explaining the rationale for restriction to promote compliance and comfort.

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    Nursing Care Plan for Patient with Excessive Fluid

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    Mr. F is a 56-year-old man with CKD stage V who presented with shortness of breath. Lab results showed azotemia, decreased hematocrit and hemoglobin, and electrolyte imbalance. He has pitting edema and does not want regular dialysis due to concerns about his business income. The nursing care plan involves assessing fluid status, limiting fluid intake, identifying fluid sources, and explaining the rationale for restriction to promote compliance and comfort.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    111 views11 pages

    Nursing Care Plan For Patient With Excessive Fluid

    Uploaded by

    Tsaabitah Anwar
    Mr. F is a 56-year-old man with CKD stage V who presented with shortness of breath. Lab results showed azotemia, decreased hematocrit and hemoglobin, and electrolyte imbalance. He has pitting edema and does not want regular dialysis due to concerns about his business income. The nursing care plan involves assessing fluid status, limiting fluid intake, identifying fluid sources, and explaining the rationale for restriction to promote compliance and comfort.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 11

    NURSING CARE PLAN FOR

    PATIENT WITH EXCESSIVE FLUID


    VOLUME RELATED TO CHRONIC
    KIDNEY DISEASE
    Tsaabitah Rizqilla Anwar, 1706039156
    Case
    Mr. F age 56 years old was treated in the disease room on the 3rd day with a diagnosis of
    CKD stage V. Currently the patient complains of shortness of breath again, after initiation
    of HD in the ER. The assessment results showed BP: 150/90 mmHg, RR: 28x / min, Pulse: 96x
    / min, pitting edema + 3 in both lower extremities, conjunctival anemic (+).
    • Lab examination results:
    • Hb 7.9 gr / dl, hematocrit 23%, erythrocytes 3 million / µL.
    • Ureum 202 mg / dl, Creatinine 8.1 mg / dl
    • Na 131, Potassium 5.1, Chloride 99.
    • AGD: Ph 7.29; PC02 25; HC03 14; P02 95; BE-11.1.
    At present the patient is receiving Lasix IV medical therapy, and oral medicines: CaCo3,
    As.Folat, Bicnat, Kalitake. Patients are planned to have regular HD 2x a week and start
    tomorrow. The patient's wife tells you that Mr. F does not want regular dialysis, because
    the family's main income comes from Mr. F's business. Patients also previously had a
    history of type 2 diabetes and did not want to take medication from a doctor, only
    wanted herbal medicine.
    ASSESSMENT
    Subjective Data Objective Data Defining Characteristics

    The patient complained of BP: 150/90 mmHg Alteration in blood pressure


    shortness of breath again
    RR: 28x/menit Alteration in respiratory pattern
    Defining Characteristics: Dyspnea
    Ereum 202 mg/dl, Creatinine 8,1
    Azotemia
    Mr F wants to avoid regular dialysis mg/dl
    Hematocrit 23% Decrease in hematocrit

    Mr.F. Patients also previously had Hb 7,9 gr/dl Decrease in hemoglobin

    history of type 2 diabetes Pitting edema + 3 in both lower


    Edema
    extremities

    Mr. F does not want to take Na 131

    medicine from a doctor, only Kalium 5,1

    wants herbal medicine Klorida 99 Electrolyte imbalance


    AGD (Ph 7,29 ; PC02 25 ; HC03 14
    ; P02 95 ; BE -11,1)
    Additional Data
    Adventitious breath sound Jugular vein distension
    Alteration in mental status Oliguria
    Alteration in pulmonary artery pressure (PAP) Orthopnea
    Alteration in urine specific gravity Paroxysmal nocturnal dyspnea
    Anasarca Pleural effusion
    Anxiety Positive hepatojugular reflex
    Hepatomegaly Presence of S3 heart sound
    Increase in central venous pressure (CVP) Pulmonary congestion
    Intake exceeds output Restlessness
    Weight gain over short period of time
    DIAGNOSIS

    Excessive Fluid Volume


    Definition:
     Surplus intake and/or retention of fluid (NANDA, 2018)
     State in which a client experiences or is at risk of experiencing
    intracellular or interstitial fluid overload (Carpenito, 2010)
    PLANNING
    The client will understand the importance of prescribed (restricted) fluid amounts.
    Demonstrates no rapid weight changes
    Maintains dietary and fluid restrictions
    Exhibits normal skin turgor without edema
    Exhibits normal vital signs
    Exhibits no neck vein distention
    Reports no difficulty breathing or shortness of breath
    Performs oral hygiene frequently
    Reports decreased thirst
    Reports decreased dryness of oral mucous membranes
    INTERVENTION
    Actions Rational

    1. Assess fluid status: 1. Assessment provides baseline and ongoing


    a. Daily weight database for monitoring changes and
    b. Intake and output balance evaluating interventions.
    c. Skin turgor and presence of edema 2. Fluid volume excess due to inefficient dialysis or
    d. Distention of neck veins repeated hypervolemia between dialysis
    e. Blood pressure, pulse rate, and rhythm treatments may cause or exacerbate HF, as
    f. Respiratory rate and effort indicated by signs and symptoms of respiratory
    2. Note presence of peripheral or sacral edema, and systemic venous congestion.
    respiratory rates, dyspnea, orthopnea, 3. Fluid restriction will be determined on basis of
    distended neck veins, and electrocardiogram weight, urine output, and response to therapy.
    (ECG) changes indicative of ventricular
    hypertrophy.
    3. Limit fluid intake to prescribed volume.
    Actions Rational
    4. Identify potential sources of fluid: 4. Unrecognized sources of excess fluids may be
    a. Medications and fluids used to take or identified.
    administer medications: oral and 5. Understanding promotes patient and family
    intravenous cooperation with fluid restriction.
    b. Foods 6. Increasing patient comfort promotes
    5. Explain to patient and family rationale for fluid compliance with dietary restrictions.
    restriction. 7. Oral hygiene minimizes dryness of oral mucous
    6. Assist patient to cope with the discomforts membranes.
    resulting from fluid restriction. 8. Accurate assessments and I&O records ensure
    7. Provide or encourage frequent oral hygiene. proper adherence to the treatment regimen
    8. Monitor laboratory reports for serum albumin and alerts the client to alterations in fluid
    level and serum electrolyte levels. balance.
    Bibliography
    Carpenito, L.J. (2010). Nursing Diagnosis: Application to Clinical Practice, 13th
    edition. USA: J.B. Lippincott Company.
    Doenges, M.E., Moorhouse, M.F. & Murr, A.C. (2010). Nursing care plans:
    Guidelines for individualizing client care accross the life span.
    Philadelphia: F.A. Davis Company.
    NANDA International. (2018). Diagnosis Keperawatan: Definisi dan Klasifikasi.
    Jakarta: EGC.
    Smeltzer, S. C., Bare, B.G., Hinkle, J.L. & Cheever, K.H. (2010). Brunner &
    Suddarth’s Textbook of Medical Surgical Nursing, 12th Edition.
    Philadelphia: Lippincott Williams & Wilkins.
    White, L., Duncan, G. & Baumle, W. (2013). Medical-Surgical Nursing: An
    integrated approach, 3rd edition. USA: Delmar Cengage Learning.

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