ASSESSMEN DIAGNOSI PLANNING INTERVENTION RATIONALE EVALUATION

T S
Excess Short term goals: Independent: • Establishing Short term goals:
Subjective: Fluid a connection
“Pakiramdam Volume Within 4 hours of • Establish can reduce Within 4 hours of
ko ang pagod related to nursing intervention Rapport patient fears nursing intervention
ko” as the patient will: and anxiety the patient will:
decreased
verbalized by
renal
the patient - The patient - The patient
function as will will
evidenced verbalized • Compare • Provides a verbalized
Objective: of Facial understandin current comparative understandin
and peri g of weight baseline and g of
Facial and orbital individual with evaluates the individual
Peri- orbital edema dietary and admission effectiveness dietary and
Edema fluid and/or of therapies. fluid
Elevated restriction previously Note: Volume restriction
Blood stated overload can (Goal met)
pressure weight. occur over
(160/80) Weigh weeks to
daily or on months in
a regular clients with
schedule, unrecognized
as kidney
Long term Goals: indicated. disease/failur Long term Goals:
e where lean
After 1-2 weeks of muscle mass After 1-2 weeks of
Nursing is lost and Nursing
Interventions the fluid overload Interventions the
patient will: occurs with patient will:
relatively little
- Stabilize fluid change in - Stabilize fluid
volume as weight. volume as
evidenced by evidenced by
balanced balanced
input and • Record input and
output, vital I&O • So that output, vital
signs within accurately adjustments signs within
client normal ; calculate can be made client normal
limits and 24-hr fluid in the fol limits and
free from balance, lowing 24-hr free from
signs of noting intake if signs of
edema plus or needed edema
minus (Goal Met)

• Set an • To prevent
appropriat exacerbation
e rate of of excess
fluid fluid volume
intake or and to
infusion prevent
throughou peaks and
t 24-hr valleys in
period fluid level

Independent:
Amlodipine 10mg OD

Collaborative:
Seek guidance and
accordance to Attending
Physician related to the
case
Joseph Syd Luiz Lao BSN-2A4

PT. Libut

Dialysis