lubrication and lipids to

the skin and provide

comfort.
12. Suggest use of tepid
water for bathing.
® Increased warmth
can increase the itch.
13. Assist with
activities of hygiene,
toileting, feeding.
® Since the patient is
dependent and need
assistance, so it is ideal
top aid the patient in
self- care activities.

Patient: X Medical diagnosis: Cellulitis in right lower extremity and Diabetes Melllitus type 2.

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 Address: Bitaog, Bansalan, Davao Su Attending physician: Dr. Sarno
Age: 79 yrs. Chief complaint: Wound Swelling at Right Leg
Fluid Volume Excess
DATE/TIME CUES NEE NSG. DIAGNOSIS OBJECTIVE OF NSG. EVALUATION
D CARE INTERVENTIONS

F OBJECTIVE: N Fluid volume excess At the end of our 1. Established rapport to February 5,
E  polyuria U related to impaired renal 8 hours span of our patient. 2010
B noted; T regulatory mechanism as care, our patient ® To gain their trust and “GOAL MET”
R R evidenced by polyuria will stabilize and cooperation.
U  VS: I Secondary to diabetes maintain adequate After our 8 hours of
A T mellitus type 2 fluid volume as 2. Obtain patient’s implementing
R Temp.= 38◦ C I evidenced by: history with regards to nursing
Y PR= 111 bpm O ® All of the normal condition. interventions, our
RR= 28 cpm N regulatory, excretory and a) balanced ® To ascertain the patient was able to
BP= 150/80 A other functions of the intake and output; probable cause of the stabilized and
05, mmHg L kidney are severely fluid disturbance, which maintained adequate
- impaired if patient has b) vital signs with can help to guide fluid volume as
M kidney problem normal limits; interventions. evidenced by:
2010 E secondary to Diabetes. a.) balanced intake
T 3. Assess patient’s fluid and output;

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 A status such as;
B a.) monitoring weight (as b.) vital signs within
@ O Bibliography: ordered) daily and normal limits
L Smeltzer, Suzanne & consistently, with same  VS:
9am I Brenda Bare.“Bruner & scale, and preferably at T= 37.3 C
C Suddarth’s Textbook of the same time of the day. PR= 92 bpm
Medical-Surgical ® Provides the best RR= 18 cpm
th
Nursing”.10 assessment of current BP= 110/70 mmHg
P Edition.Lippincott fluid status and
A Williams & adequacy of fluid
T Wilkins.Philadelphia.200 replacement.
T 4
E B.)measuring abdominal
R girth
N ® For changes that may
indicate increasing fluid
retention/edema.

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