Nursing Care Plan
Client 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 related to compromised regulatory mechanism secondary to end-stage renal failure as evidence by peripheral edema and patient’s weight gained from 69.8kg to 73.6kg within 4 days. Assessment
Goals & Expected Outcomes
Methods of Evaluation
1. The client claimed her weight started to gain quickly 2 weeks before admission.
2. The client 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 SOB and orthopnoea
1. Pressing thumb for 5s into the limbs’ skin and removed quickly resulted in pitting and graded at +1.
2. The client’s weight gained from 69.8kg to 73.6kg from 25/11/2012 to 29/11/2012.
3. Reduced CAPD output was noted.
4. Shifting dullness on abdomen was noted.
Dysfunctional health pattern:
Nutrition and Metabolism
Excess fluid volume
related to compromised regulatory mechanism secondary to end-stage renal failure
Signs & symptoms :
1. Client’s weight gained from 69.8kg to 73.6kg within 4 days.
2. Peripheral edema graded at +1.
The client will exhibit decreased edema on peripheral.
1. The client can regain fluid balance as evidenced by weight loss accessed by3/12/2012
2. 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 3/12/2012
4. The client will demonstrate 2 method to help reduce edema by 3/12/2012 1. Ongoing assessments
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