Nursing Care Plan Essay

thickening name Mrs. Chan Age/ sex 48/F Medical diagnosis Fluid hook, decreased TK output and decreased Hb Assessment get a line 25-11-2012 Diagnostic statement (PES) Excess bland volume related to compromised restrictive mechanism secondary to end-stage nephritic failure as evidence by peripheral oedema and patients slant gained from 69.8kg to 73.6kg at bottom 4 days.AssessmentNursing DiagnosisGoals & Expected OutcomesNursing InterventionsRationalesMethods of military ratingSubjective data1. The lymph node claimed her weight started to gain quickly 2 weeks out front admission.2. The lymph gland 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 orthopnoeaObjective data1. Pressing throw 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 25/11/2 012 to 29/11/2012.3. Reduced CAPD output was noted.4. Shifting dullness on abdomen was noted. dysfunctional health patternNutrition and MetabolismProblemExcess fluid volumeEtiology related to compromised regulatory mechanism secondary to end-stage renal failureDefining characteristics/Signs & symptoms 1. guests weight gained from 69.8kg to 73.6kg within 4 days.2. Peripheral edema graded at +1.GoalsThe client ordain exhibit decreased edema on peripheral.Expected outcomes1. The client foot regain fluid balance as evidenced by weight loss accessed by3/12/20122. The client leave alone be able to babble 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 3/12/20124. 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 routine2. Therapeutic interventionsa) Intro duce the needs for low sodium diet and the depress the fluid intake less than 800mlb) Apply stockings while lying win and check extremities frequently for adequate circulation.c) Advise the client to elevate her feet when session3. Education for client and caregiversa) Plan ROM exercise for all extremities each 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 standned and frozen victuals and cook without salt and use spices to add flavour. 1a) Weight client free-and-easy 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 gain 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 extremiti es. (Gulamick & Myers, 2007)3a) assure skeletal muscles increase lymph flow and 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 tincture of thirst to drink 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 decrease edema.4. Ask the client to record the menu eaten for checking the eating habits.5. Ask the client to verbalize syndromes of edema.