Jann Reinna C.

Palma
De La Salle Lipa-BSN G3B3
NURSING CARE PLAN
Assessment Nsg Dx Case Bg Planning Intervention Rationale Evaluation

Subjective
● The
patient
Excessive fluid
volume related to ⬇️
Tobacco Smoker

Ischemic Heart
Short-term
After 2 hours of
nursing Note the
INDEPENDENT

It may contribute
Short-term
After a series of
nursing
compromised

⬇️
verbalized regulatory Disease intervention, the presence of to excess fluid interventions, the
that mechanism as patient will medical intake or retention goal is met as the
“Manas evidenced by Chronic Kidney understand conditions or patient is able to

⬇️
yung paa edema Disease individual dietary situations. understand
ko, pero di and fluid individual dietary

⬇️
naman Edema restrictions, Review nutritional Imbalances in and fluid
masakit”. monitor fluid issues these areas are restrictions,
Excessive fluid status by associated with monitors fluid
Objective volume identifying the fluid imbalances. status by
● (+) Edema amount of her identifying the
● BP: intake as well as Compare current This provides a amount of her
140/100 her output, and weight with comparative intake as well as
reduce admission and/or baseline and her output, and
recurrence of fluid previously evaluates the reduces
excess. stated weight. effectiveness of recurrence of fluid
therapies. excess.
Long-term
After 8 hours of Auscultate breath To identify Long-term
nursing sounds presence of After a series of
interventions, the crackles, nursing
patient will have a congestion. interventions, the
stabilized fluid goal is partially
volume as Measure and Pressures may met as the patient
evidenced by record the vital be high because did not fully
balanced input signs of the pt. of excess fluid stabilized her fluid
and output (I&O), volume or low if volume as
vital signs within cardiac failure is evidenced by her
client’s normal occurring. bipedal edema.
Jann Reinna C. Palma
De La Salle Lipa-BSN G3B3

limits, stable However, the

weight, and free Note the Heart failure and patient had a
of signs of presence and renal failure are balanced input
edema. location of edema associated with and output (I&O),
depen- dent and vital signs
edema because are within the
of hydrostatic client’s normal
pressures, with limits.
depen- dent
edema being a
defining
characteristic for
excess fluid.

Measure and This provides a

record I&O comparative
baseline and
evaluates the
effectiveness of
therapies.

Elevate To prevent
edematous pressure ulcers
extremities and
change position
frequently

Educate the To understand

patient the reason that it may
why she is not increase the
receiving an IV severity of her
Therapy edema
Jann Reinna C. Palma
De La Salle Lipa-BSN G3B3

DEPENDENT

Administer To reduce
medications such congestion and
as Diuretics as edema if heart
prescribed failure is the
cause of fluid
overload.

Administer To manage the

somatostatin as patient’s heart
prescribed disease and
blood pressure

Assist with This may be done

procedures as to correct volume
indicated overload, correct
(dialysis)/ if electrolyte and
needed acid-base
imbalances, or
improve cardiac
function
and support the
patient during
shock state.

COLLABORATIVE

Consult with the To develop

dietitian as dietary plan and
needed identify foods to
be limited or
omitted
Refer to
Jann Reinna C. Palma
De La Salle Lipa-BSN G3B3

appropriate To support the

community patient
resources, emotionally
diabetic educator,
and/or support
groups, as
needed

Review with the

patient and SO To provide proper
the dietary management and
restrictions and avoid making the
safe substitutes condition worse.
for salt (e.g.,
lemon juice or
spices, such as
oregano)

Discuss the
importance of To prevent
fluid restrictions increased fluid
and “hidden volume in the
sources” of fluid body that can
intake to SO/ cause harm into
family the patient’s
kidney