Nursing Care Plan Essay

guest name Mrs. Chan Age/ sex 48/F Medical diagnosis Fluid overload, decreased TK output and decreased Hb Assessment date 25-11-2012 Diagnostic statement (PES) Excess fluid volume link to compromised regulatory mechanism secondary to end-stage renal failure as evidence by peripheral oedema and patients weight gained from 69.8kg to 73.6kg indoors 4 days.AssessmentNursing DiagnosisGoals & Expected OutcomesNursing InterventionsRationalesMethods of EvaluationSubjective data1. The node claimed her weight started to gain quickly 2 weeks before admission.2. The invitee reported of taut and shiny skin appeared on the limbs and face.3. The client complained on decreasing urinary output 2 weeks before admission.4. The client complained of increasing horseshit and orthopnoeaObjective data1. Pressing thumb for 5s into the limbs skin and removed quickly resulted in pitting and graded at +1.2. The clients weight gained from 69.8kg to 73.6kg from 25/11/2012 to 29/11/2012.3. Reduced CAPD outpu t was noted.4. Shifting dullness on abdomen was noted.Dysfunctional health patternNutrition and Metabolism choreExcess 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 edema graded at +1.GoalsThe client will exhibit decreased edema on peripheral.Expected outcomes1. The client kindle find out fluid balance as evidenced by weight loss accessed by3/12/20122. The client will be able to verbalize the restricted totality of necessary dietary like sodium and fluid as prescribed by 3/12/2012.3. The client will be able to show up 1 method to access edema by 3/12/20124. The client will demonstrate 2 method to help reduce edema by 3/12/2012 1. Ongoing assessmentsa) Record 24hrs intake and output balance.b) Weigh at 0600 and 1800 daily2. Therapeutic interventionsa) Introduce the needs for low sodium diet and the lower the flu id intake less than 800mlb) Apply stockings while lying down and check extremitiesfrequently for adequate circulation.c) Advise the client to set ahead her feet when sitting3. Education for client and caregiversa) Plan ROM 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 add 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) Contracting skeletal muscles increase lymph flow a nd reduce edema. (Carpenito, L. J., 2010) b&c) Client and caregiver can help monitor and control fluid overload ( Lewis& Sharon Mantik., 2011) d) Restrict the sodium intake can decrease the feeling of thirst to beverage water. ( Gulamick & Myers, 2007)1. Keep checking on the change of clients weight.2. Assess the clients edema condition every day by pressing.3. Ask the client to demonstrate the method for accessing and reducing edema.4. Ask the client to record the menu eaten for checking the eating habits.5. Ask the client to verbalize syndromes of edema.