Assessment

Subjective: Namamanas ako. (I have edema) as verbalized by the

patient.
Objective: Generalize edema
Increase blood pressure
Decrease urine output (less than 400)
Increase urea
Creatinine level in blood
Nursing Diagnosis
Fluid volume excess r/t compromised regulatory mechanism
Objective/Goals
After 8 hours of nursing intervention the patient will be able to:

Display

gravity/laboratory studies near normal.

Establish stable weight, vital signs within patients normal

appropriate

urinary

output

with

specific

range; and absence of edema.

Nursing Intervention
Independent

Record accurate intake and output (I & O)

Assess skin, face, and dependent areas for edema
Weigh daily at same time of day, on same scale, with

same equipment and clothing.

Assess level of consciousness. Investigate changes in
mentation, presence of restlessness.

Collaborative

Administer and/or restrict fluids as indicated.

Administer medication as indicated.

Rationale

Accurate I & O is necessary for determining renal function

and fluid replacement needs and reducing risk of fluid

overload
Edema occurs primarily in dependent tissues of the body
Daily body weight is best monitor of fluid status. A weight

gain of more than 0.5 kg/day suggests fluid retention.

May reflect fluid shifts, accumulation of toxins, acidosis,

electrolyte imbalances, or developing hypoxia.

Fluid management is usually calculated to replace output
from

all

sources

plus

estimated

insensible

losses

(metabolism, diaphoresis).
Given early in oliguric phase renal failure in an effort to
convert to nonoliguric phase, flush the tubular lumen of
debris, reduce hyperkamelia, and promote adequate urine
volume.

Evaluation
Goals met.
After 8 hours of nursing intervention patient has displayed
appropriate urinary output with specific gravity/laboratory studies near
normal (more than 400), BP decreased, ideal body weight is
maintained, no neck vein distended and absence of edema.

ASSESSMENT
SUBJECTIVE:
Nanghihina yong katawan ko. (I feel weak) as verbalized by the
patient.
OBJECTIVE:
Tremors
Dry skin
HPN
Weakness
SOB
NURSING DIAGNOSIS
Activity Intolerance r/t fatigue
OBJECTIVE/GOALS
After 8 hours of nursing intervention patient will be able to maintain
activity level within capabilities as evidenced by normal HR, BP during
activity and absence of SOB, weakness, and fatigue.
NURSING INTERVENTION

Monitor Vital signs

Assist in performing activities in fatigued and Encourage alternating
activity with rest.
RATIONALE
Fever (higher than 100.4F) with increased pulse and respirations is
typical of increased metabolic rate resulting from inflammatory
process, although sepsis can occur without a febrile response.
Reduces oxygen consumption and cardiac workload.

EVALUATION
After 8 hours of nursing intervention patient will maintain activity level
within capabilities as evidenced by normal HR, BP during activity and
absence of SOB, weakness, and fatigue.

DISCHARGE PLAN

MEDICATION
Discuss/instruct to the patient with their significant other the
importance as prescribe by the physician.
Emphasize on compliance to therapeutic and medication regimen and
the information regarding side effect of the medications.
RATIONALE
Patient with their significant other need to understand the occurrence
of the drug effects in order to when, what and whom to report on any
symptoms present.

ECONIMIC STATUS
Pinpoint the patient their capability to purchase the medications.
The patient accessibility to the agency and should be considered with
regards to follow-up.
RATIONALE
This is to make sure that the compliance of the medication will be
achieved.
To have immediate interventions when signs and symptoms occur.

TREATMENT
Compliance to medication regimen.
RATIONALE
To have a fast recovery and to prevent complications.

HEATH TEACHING
Encourage the patient to prevent the stressful activity and have
adequate rest.
RATIONALE
To promote early recovery.

OUT-PATIENT
Emphasize the patients to schedule for regular follow-up appointment,
and discuss the importance of regular check up care.
RATIONALE
To monitor any alternations in the patients status and ensure
compliance to medication regimen.

DIET
Instruct patient to eat adequate calorie intake, especially from
carbohydrates in the nondiabetic patient.
RATIONALE
For Spares protein, prevents wasting, and provides energy.

SPIRITUALITY
Allow the patient to pray if possible all the time to God.
RATIONALE

To provide and optimistic approach towards her/his problem.