1

2
Subjective:
nde ko na
magalaw ng
maayos itong paa
ko simula nung
lumaki at tumaba
na ito, nakaka
ngalay as
verbalized by the
patient
Objective:
- +3 edema
on both foot
- +2 edema
on both
hands
- (+)
periorbital
edema
- (+)
proteinuria
- 30 ml urine
output for
the last
hours
Fluid volume
excess
related to
de!reased
glomerular
filtration rate
"hort term
goal#
$lient will
have an
in!reased
urine output of
%0&0 ml for
the ne't (
hours)
*ong term
goal#
$lient will
have a
sustained
minimum
urine output of
20 ml per hour
and manifest
lesser edema
(+) +)
Assessment:
1. Obtain complete
physical
assessment.
2. Monitor daily
ei!ht.
". Monitor #luid inta$e
and output every %
hours.
%. Monitor &' and '(
every
hour.
). Assess #or
adventitious breath
sounds.
+) ,o have baseline
data on the progress
of fluid elimination
through physi!al
appearan!e)
2) ,o have a
measurable a!!ount
on the fluid
elimination)
3) ,o know
progressing
!ondition via
glumerular filtration)
-) ,o know
progression of
hypertension and
basis for further
nursing intervention
or referral)
.) ,o know for
possible progression
in the lungs)
$lient had a total
urine output of %2
ml - hours after
the implementation
of the nursing
interventions)
$lient had edema
of (+) + the se!ond
day of nursing
intervention)
/atient also had an
average of 2- ml
of urine output for
the last +0 hours)
3
- 0ital signs#
1/2+-0340
/52+20 bpm
*. Monitor laboratory
values especially #or
the protein level in the
urine.
+reatment:
1. Maintain dietary
restrictions durin!
acute phase.
a. sodium
b. protein
2. Maintain #luid
restriction
". ,levate extremities
() ,o know the
e'tent of protein loss
whi!h led to edema)
+)
a) to help prevent
fluid retention
via absorption)
b) it helps prevent
fast elevation of
167 level)
2) 8elps prevent
further fluid
a!!umulation while
there is de!reased
glumerular filtration)
3) 8elps fluid
4
ith pillos hen at
rest or at lyin!
position.
%. Administer diuretics
as ordered.
).Administer
antibiotics as ordered.
*. Administer anti
hypertensive dru!s as
ordered.
,ducative:
1. ,ncoura!e
ambulation and
non strenuous
exercises.
2. +each on the
importance o#
e'!retion via gravity)
-) 8elps e'!rete
e'!ess fluids through
pharma!ologi!al
rea!tion)
.) 9ights infe!tion
and progression of
s!arring)
() $ontrols
hypertension as
!aused by e'!essive
fluid)
+) 8elps in!rease
blood and fluid
!ir!ulation)
2) 5einfor!es
awareness on its
effe!t on fluid
5
elevatin! extremities
hen at rest.
". ,ncoura!ed to
maintain
clean and moist
s$in.
%. ,ncoura!ed to stic$
on dietary and #luid
restrictions.
e'!retion)
3) 8elps prevent skin
breakdown and
further infe!tion
arising from the
skin)
-) 9or !lient
!ooperation even in
the absen!e of any
medi!al pra!titioner)
6
7