Nursing Care Plan

Topics: Pain, Nursing, Nursing care plan Pages: 3 (1083 words) Published: April 23, 2014
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

Nursing Diagnosis
Goals & Expected Outcomes
Nursing Interventions
Rationales
Methods of Evaluation
Subjective data:
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

Objective data:
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
Problem:
Excess fluid volume

Etiology:
related to compromised regulatory mechanism secondary to end-stage renal failure

Defining characteristics/
Signs & symptoms :

1. Client’s weight gained from 69.8kg to 73.6kg within 4 days.

2. Peripheral edema graded at +1.
Goals:
The client will exhibit decreased edema on peripheral.

Expected outcomes:
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
a)...
Continue Reading

Please join StudyMode to read the full document

You May Also Find These Documents Helpful

  • care plan Essay
  • Care Plan Essay
  • Nursing Care Plan: Teaching Essay
  • Nursing Care Plan Essay
  • Nursing Care Plan Essay
  • Care Plan Essay
  • Nursing Care Plan: Terminal Illness and End-of-Life Essay
  • Care Plan Post Op Essay

Become a StudyMode Member

Sign Up - It's Free