Assessment Subjective: Bago pa siya ma-admit sa ospital, wala naman pamamaga sa binti at kamay niya pero ngayon habang

tumagal kami sa ospital, ayun namaga na hanggang ngayon kaya bumigat na rin siya lalo. As verbalized by the patients grandson in-law. Objectives: RR: 32 breaths per minute PR: 101 bpm (+) crackles Pitting edema 1+ Hypertensio n Altered electrolytes

Diagnosis Fluid volume excess related to drug therapies secondary to stroke as manifested by (+) crackles, pitting edema 1+, hypertension and weight gain.

Rationale Increased isotonic fluid retention due to presence of underlyin g illness condition.

Planning After 8 hours of nursing interventio n the patient will demonstrat e stabilized fluid volume with clear breath sounds, vital signs within acceptable range, stable weight and absence of edema.

Intervention Independent: 1. Monitor 24-hour intake and output.

Rationale

Diuretic therapy may result in excessive fluid loss, even though edema remains. 2. Weigh daily. Documents change in/resolution of edema in response to therapy. 3. Inspect dependent Peripheral edema begins in body areas for edema feet/ankles and ascends as with/without pitting. failure worsens. 4. Auscultate breath Excess fluid volume often sounds. leads to pulmonary 5. Monitor BP congestion. Hypertension suggests fluid volume excess and may 6. Note increased reflect in developing HF. lethargy, hypotension and Signs of potassium and muscle cramping. sodium deficits that may occur because of fluid shifts 7. Review laboratory and diuretic therapy. data. To evaluate degree of fluid and electrolyte imbalance and response to therapies. 8. Elevate edematous To reduce tissue pressure and extremities and change risk of skin breakdown. position frequently. 9. Place in semi-fowlers position, as appropriate. To facilitate movement of diaphragm, thus improving respiratory effort. 10. Provide quiet To provide rest and lessen environment, limiting discomfort. external stimuli. 11. Use safety To prevent for further precautions by raising

Evaluation After 8 hours of nursing intervention the patient demonstrated stabilized fluid volume with clear breath sounds, vital signs within acceptable range, stable weight and absence of edema.

both side rails at all times. 12. Instruct patients family to provide frequent oral care, use of petroleum jelly or water to lips. Dependent: 1. Administer medications as indicated Diuretics Potassium supplement Beta-Blockers 2. Maintain fluid/sodium restrictions as indicated.

injury/fractures. To reduce discomfort of fluid restrictions.

Diuretics rate of urine flow and may inhibit reabsorption of Sodium/chloride in the renal tubules. Replaces potassium that is lost as common side effect of diuretics. Lowers blood pressure. Reduces total body water/prevents fluid reaccumulation. To promote optimal wellness.

Collaborative: 1. Consult dietician, as needed.