Trixia T.

Camporedondo 4AN2 Intensive Care Unit August 26-27, 2014

Assessment Diagnosis Inference Goal Intervention Rationale Evaluation

Subjective:
Patient is in ET and
unconscious.



Objective:
Hypotension
90/70 mmHg
Tachycardia 114
bpm
Anasarca
Decreased
urinary output
100cc
Lethargic

Excess Fluid
Volume
related to
compromised
regulatory
mechanism
as evidenced
y edema.

HASCVD


Decreased
Ventricular
contraction


Ventricular
overload


Tachycardia


Ventricular
Dilatation


Myocardial
Hypertrophy


Decreased
cardiac
output



Short Term:
After 30
minutes of
nursing
intervention
patients vital
signs will be in
normal range.

Long Term:
After of 5
hours
of nursing
interventions,
the patient
will be able to
stabilize fluid
volume as
evidenced by:
a.
Balance intake
and output;
b. Drain at
least 1liter of
urine and
foley catheter

Independent:

Monitor vital
signs.




Auscultate
lungs and
heart sound.





Assess for
presence/
location of
edema.


Note for
presence of
neck and
peripheral
vein
distention.



Tachycardia
and
hypertension
are common
manifestation.

Adventitous
sounds
(crackles) and
extra heart
sound(s3) are
indicative of
fluid excess.

Edema can be
either a cause
or a result of
various
pathologic.

Signs of cardiac
decompensatio
n





Short Term:
After 30
minutes of
nursing
intervention
patients vital
signs was in
normal range.

Long Term:
After of 5 hours
of nursing
interventions,
the patient was
able to
stabilize fluid
volume as
evidenced by:
a.
Balanced intake
and output;
b. Drain at
least 1liter of
urine and foley
catheter

Trixia T. Camporedondo 4AN2 Intensive Care Unit August 26-27, 2014

Decreased
renal
perfusion



Increased
sodium
retention


Increased
osmotic
pressure


Increased
antidiuretic
hormone


Increased
water
reabsorption


Fluid
overload
Edema


Maintain
accurate I and
O. Note
Decreased
urinary
output.





Weigh as
indicated. Be
alert for acute
or sudden
weight gain.

Monitor
infusion rate
or parenteral
fluids closely;
administer via
control
device/
infusion pump
as necessary.


Maintain a
Semi-Folwer
position.
Decreased
renal perfusion,
cardiac
insufficiency,
and fluid shifts
may cause
decreased
urinary output
and edema
formation.

One liter of
fluid retention
equals a weight
gain of 2.2 lbs.


Sudden fluid
bolus/
prolonged
excessive
administration
potentiates
volume
overload or risk
of cardiac
decompensatio
n.
Gravity
improves lung
expansion by
Trixia T. Camporedondo 4AN2 Intensive Care Unit August 26-27, 2014








Turn,
reposition,
and provide
skin care at
regular
intervals.

Provide safety
precautions;
raise the side
rails and self
restraint.

Collaborative:

Monitor
laboratory
includes BUN,
ABG's and
electrolytes.



Administer
lowering
diaphragm and
shifting fluids
lower
abdominal
cavity.

Reduces
pressure and
friction in
edematous
tissue.


Note: Use of
restraint may
increase
agitation and
can pose a
safety threat.


Extracellular
fluid shifts,
sodium/ water
restriction and
renal function
all affect serum
sodium levels.

To achieve
Trixia T. Camporedondo 4AN2 Intensive Care Unit August 26-27, 2014

diuretics as
ordered by
the physician:
loop diuretics
e.g.,
Furosemide
(Lasix).
excretion of
fluid.