Nursing Care Plan Essay

thickening name Mrs. Chan while/ sex 48/F Medical diagnosis Fluid overload, lessen TK outturn and decreased Hb Assessment date 25-11-2012 Diagnostic line of reasoning (PES) Excess fluid volume associate to compromised regulatory mechanism subaltern to end-stage renal failure as evidence by peripheral dropsy and patients burden gained from 69.8kg to 73.6kg within 4 days.Assessment nurse DiagnosisGoals & Expected OutcomesNursing InterventionsRationalesMethods of EvaluationSubjective data1. The thickening claimed her weight started to gain quick 2 weeks before admission.2. The lymph gland inform of taut and shiny hide appeared on the limbs and face.3. The client complained on fall urinary output 2 weeks before admission.4. The client complained of increasing dirt and orthopnoeaObjective data1. Pressing thumb for 5s into the limbs skin and removed quickly resulted in pitting and range at +1.2. The clients weight gained from 69.8kg to 73.6kg from 25/11/2012 to 29/11/2012 .3. Reduced CAPD output was noted.4. change over dullness on abdomen was noted.Dysfunctional health pattern victuals and MetabolismProblemExcess fluid volumeEtiologyrelated to compromised regulatory mechanism secondary to end-stage renal failureDefining characteristics/Signs & symptoms 1. Clients weight gained from 69.8kg to 73.6kg within 4 days.2. Peripheral dropsy graded at +1.GoalsThe client go out exhibit decreased edema on peripheral.Expected outcomes1. The client can regain fluid balance as evidenced by weight loss accessed by3/12/20122. The client will be able to verbalize the restricted amount of necessary dietary like sodium and fluid as prescribed by 3/12/2012.3. The client will be able to demonstrate 1 method to access edema by 3/12/20124. The client will demonstrate 2 method to help shorten edema by 3/12/2012 1. Ongoing assessmentsa) Record 24hrs stirring and output balance.b) Weigh at 0600 and 1800 daily2. Therapeutic interventionsa) Introduce the needs for beginn ing sodium diet and the lower the fluid intake less than 800mlb) entertain stockings while lying down and check extremitiesfrequently for adequate circulation.c) suggest the client to elevate her feet when sitting3. Education for client and phencyclidine hydrochloridesa) Plan read-only storage exercise for all extremities every 4hb) Teach pressing thumb for 5s into the skin and grading if appear in pitting.c) Educate the sign and syndromes of edema.d) Teach to avoid canned and frozen food and cook without salt and use spices to enlarge flavour. 1a) Weight client daily can monitor trends to evaluate interventions.( Lewis& Sharon Mantik., 2011) b) monitor IO chat can determine effect of treatment on kidney function( Lewis& Sharon Mantik., 2011)2a) High-sodium intake leads to increase water retention(Carpenito, L. J., 2010) b) Compression stockings increase venous return and reduce venous pooling. (Carpenito, L. J., 2010) c) This prevent fluid accumulation in the lower extremities . (Gulamick & Myers, 2007)3a) spying skeletal muscles increase lymph flow and reduce edema. (Carpenito, L. J., 2010) b&c) Client and caregiver can help monitor and control fluid overload ( Lewis& Sharon Mantik., 2011) d) set the sodium intake can decrease the feeling of thirst to tipsiness water. ( Gulamick & Myers, 2007)1. Keep checking on the change of clients weight.2. Assess the clients edema condition every day by pressing.3. hire the client to demonstrate the method for accessing and reducing edema.4. Ask the client to track record the menu eaten for checking the eating habits.5. Ask the client to verbalize syndromes of edema.