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NCP - Excessive Fluid Volume

The nursing care plan is for a patient experiencing excess fluid volume due to reduced kidney function. The plan includes monitoring urine output, daily weight, and intake/output to evaluate the patient's fluid status. Nursing interventions like bed rest, fluid restrictions, and diuretic medication aim to stabilize the patient's fluid volume. After 8 hours of nursing care, the goals of stabilized vital signs and clearing symptoms were partially met.

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1K views4 pages

NCP - Excessive Fluid Volume

The nursing care plan is for a patient experiencing excess fluid volume due to reduced kidney function. The plan includes monitoring urine output, daily weight, and intake/output to evaluate the patient's fluid status. Nursing interventions like bed rest, fluid restrictions, and diuretic medication aim to stabilize the patient's fluid volume. After 8 hours of nursing care, the goals of stabilized vital signs and clearing symptoms were partially met.

Uploaded by

ryan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CUES

NURSING
DIAGNOSIS

SCIENTIFIC
BASIS

Subjective:
nanghupong
ang
akong
asawa
as
verbalized by
the
patients
husband.

Objective:
Respiratory
distress,
Hypertension,
Tachycardia
and Edema

Excess fluid
volume r/t
reduced
glomerular
filtration
rate(decrease
d cardiac
output)/increa
sed
antidiuretic
hormone
(ADH)
production,
and
sodium/water
retention

Increased
isotonic
retention

GOALS
&OUTCOME
CRITERIA

After 8 hours of
nursing
intervention the
fluid client will be able
to:
-

Demonstra
te
stabilized
fluid
volume
with
balance
intake and
output,
breath
sound
clear/cleari
ng, vital
signs
within
acceptable
range, and
absence of
edema.
Verbalized
understan

NURSING
ACTIONS AND
NURSING
ORDERS

RATIONALE OF
NURSING ORDERS

Independent:
-

Monitor
urine
output,
noting
amount ad
color, as
well as
time of
day when
diuresis
occurs.
Monitor/cal
culate 24hour
intake and
output(I&O
)

Maintain
chair or
bed rest in
semiFowlers
position

Urine output may


be scanty and
concentrated
(especially during
day) because of
reduced renal
perfusion.

Diuretic therapy
may result in
sudden/excessive
fluid loss, even
though
edema/ascites
remains.

Recumbency
increase
glomerular
filtration and
decreases
production of
ADH, thereby
enhancing

EVALUATION

After 8 hours of
nursing
intervention,
the
patient was able
to:

Demonstrat
e stabilized
fluid volume
with balance
intake and
output,
breath
sound
clear/clearin
g, vital signs
within
acceptable
range, and
absence of
edema.
Verbalized
understandi
ng of
individual
dietary/fluid

ding of
individual
dietary/flui
d
retractions
.
Demonstra
te
behaviors
to monitor
fluid status
and reduce
recurrence
of fluid
excess.
List signs
that
requires
further
evaluation.

during
acute
phase.
-

diuresis.
-

Weigh
daily

Document
changes
in/resolution of
edema in
response to
therapy.

retractions.

Collaborative:
Administer
medications as
indicated:
-

Furosemid
e (Lasix)

Maintain
fluid/sodiu
m
restrictions
as
indicated.

Increase rate of
urine flow and
may inhibit
reabsorption of
sodium/chloride
in the renal
tubules.
Reduce total
body water/
prevents fluid
reaccumulation.

Demonstrat
e behaviors
to monitor
fluid status
and reduce
recurrence
of fluid
excess.
Was able to
note
signs
that requires
further
evaluation.

Goals
partially
met.

NURSING CARE PLAN


Patients Name:
Hospital No.:
Age:
Room No.:
CLINICAL PORTRAIT

PERTINENT DATA

Impression:
Physician:
Nurses Name & Signature:

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