University:
American Career College
Course:
NURS112 | Fundamentals of Nursing
Academic year:

2020
Views:

334

Pages:

1
Author:

Nesbyenvkk

Care Plan for Excess Fluid Volume example (NOT A REAL PERSON, FAKE PATIENT) Nursing Problem: 1+ edema in feet bilaterally, weight gain by 7 pounds within 2 weeks, poor renal function, diabetes, gout, congestive heart failure, pneumonia Collaborative Problems: Dietician would also be helpful with the patient’s poor renal function, as they can provide nutrition and dietary guidelines that would help that. Patient is a fall risk so physical therapy will help regain strength and stability. Respiratory therapy can help the patient with breathing mechanisms to prevent them from getting pneumonia again. Nursing Dx: Excess Fluid Volume o (R/T): Renal insufficiency, compromised regulatory mechanism, congestive heart failure, fluid retention (1+ edema) o (AEB): 1+ edema, in feet bilaterally, weight gain of 7 pounds within 2 weeks, abnormal breath sounds, crackles, slightly decreased HGB of 10.1, dyspnea on exertion Client Outcome: Patient will not gain more than 3 pounds in 2 weeks. Patient verbalizes how to properly breathe to keep lungs full by taking deep breaths, within 24 hours. Patient’s edema will be reduced from a 1+ to 0 within 24 hours. Patient’s HGB will rise from a 10.1 to a 10.5 within 72 hours. Patient has clear lung sounds, demonstrated by absence of crackles, with in a week. Subjective Data: “My feet look big.” “I am feeling weak.” Objective Data: 1+ edema in feet bilaterally, weight gain of 7 pounds within 2 weeks, slightly low HGB of 10.1, crackles in lungs, dyspnea on exertion Nursing Interventions and Rationales: o 1) Nursing Intervention: Monitor location and extent of edema using the 1+ to 4+ scale. (Rationale): Causes of peripheral edema in clients with heart failure are related to medications, compensatory changes that influence hydrostatic pressure, and fluid retention, among other things. (Cooper, 2011) o 2) Nursing Intervention: Monitor daily weight for sudden increase. (Rationale): Body weight is commonly used to monitor for fluid overload. (Wagner & Hardin-Pierce, 2014) o 3) Nursing Intervention: Monitor intake and output. (Rationale): Accurately measuring intake and output is important for the client with fluid volume overload. (Macedo et al, 2011)