Microsoft Word - Care Plan actual week 3 PDF

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Summary

care plan for medical surgical fall risk patient....

Description

Selected Nursing Diagnosis hypervolemia r/t excess fluid evidenced by edema in left arm. Goal/Outcome Criteria: ST goal: Client will verbalize understanding of individual dietary and fluid restrictions by end of shift. LT goal: Client will display stable fluid volume as evidence by absence of signs of edema by discharge.

Assessment Data Cluster Subjective Symptoms “client stated she was not hungry but thirsty” “client stated she was not in pain”

Nursing Interventions Assessment Interventions: Weigh client daily. Observe for sudden weight gain. Monitor intake and output. Note decreased urinary output and positive fluid balance on 24-hour calculations.

Objective Signs:

Rationale (Include Source) “One liter of fluid retention equals a weight gain of 1 kilogram (2.2 pounds).” (Ackley,et al, 2020, p. 577) “Decreased renal perfusion, cardiac insufficiency, and fluid shifts may cause decreased urinary output and edema formation.” (Ackley,et al, 2020, p. 577)

Therapeutic Interventions: Edema present in left arm Vitals stable Stats at 100% on oxygen

Encourage deep breathing and coughing exercises. Maintain semiFowler’s position if dyspnea or ascites is present.

Teaching Interventions:

Revised 8/6/2008

“Pumonary fluid shifts potentiate respiratory complications.” (Ackley,et al, 2020, p. 578) “Gravity improves lung expansion by lowering diaphragm and

Goal Evaluation ST goal met: client was in agreement and aware she was on a restricted diet to cater to fluid balances. LT goal not met: client was not able to be discharge due to fluid excess and edema still present in LA.

Evaluate client’s ability to manage own hydration. encourage foods with high fluid content.

shifting fluid to the lower abdominal cavity.” (Ackley,et al, 2020, p. 578) “Impaired gag and swallow reflexes, anorexia, oral discomfort, nausea, and changes in mentation are among factors that affect client’s ability to replace fluids orally.” (Ackley,et al, 2020, p. 579) “Relieves thirst and discomfort of dry mucous membranes and augments parenteral replacement.” (Ackley,et al, 2020, p. 579)

Revised 8/6/2008...