Nursing Care Plan

 


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Medical Diagnosis: Excess Fluid Volume, Congestive Heart Failure, Renal Failure

Assessment

2

Nursing DX/Clinical Problem

1.95

Client Goals/Desired Outcomes/Objectives

2

Nursing Interventions/Actions/Orders and Rationale

2

*I

Evaluation

2

Goals

Interventions

Subjective

Patient’s statement:

“I don’t restrict my fluid as much as I was instructed.”

               

“I get out of breath quickly without my oxygen.”

               

               

               

Objective

Cr- 4.03

Hgb- 9.4

Hct- 29.3

Cap Refill- 3 seconds

Diminished breath sounds in bilateral lower lobes

         


Problem

Excess fluid volume

         

Ineffective tissue perfusion 

Long Term:

Explain measures that can be taken to treat or prevent excess fluid volume by discharge.

               

Demonstrate adequate tissue perfusion until discharge.

Teach the importance of fluid and sodium restrictions.

EBP:  Fluid restriction will reduce myocardial workload and sodium restriction will promote excretion of excess fluid (Ackley and Ladwig, pg. 377).

               

Check capillary refill

EBP: nail beds return to usual color within 2-3 seconds (Ackley and Ladwig, pg. 845).

               

Goal not met, progress made. At end of shift on [date], patient was able to explain the importance of restricting fluid and sodium intake.

               

Goal not met, patient’s capillary refill upon [date] AM assessment was 3 seconds.

Patient taught and able to verbalize importance of fluid and sodium restrictions. [date] AM assessment will include another teaching to assist patient in achieving goal.

               

Capillary refill checked during AM assessment. 3 seconds indicates effective tissue perfusion but is not ideal. Capillary refill will be reassessed with [date] AM assessment.

R/T

CHF and renal failure

         

decreased oxygen supply to the blood

Short Term:

Describe symptoms that indicate the need to consult with health care provider by the end of [date] AM assessment.

               

By the end of the AM assessment on [date], patient will identify changes in lifestyle needed to increase tissue perfusion.

Teach about signs and symptoms of both excess and deficient fluid volume and when to call physician.

EBP: Fluid balance can change rapidly (Ackley and Ladwig, pg. 378).

  

Keep the client warm and have the client wear socks and shoes when mobile. DO NOT apply heat.

EBP: Maintains vasodilation and blood supply. Heat can damage ischemic tissues (Ackley and Ladwig, pg. 345).

               

Goal met. Patient was able to correctly identify symptoms that would indicate need to contact physician.

               

Goal met, patient was able to correctly identify lifestyle changes that need to be made in order to promote optimal tissue perfusion.


Teaching took place after AM assessment, patient was able to verbalize the signs and symptoms to nurse. Short term goal is to be re-evaluated on [date].

               

Patient was given blankets, TED hose, and non skid socks. Water temperature of bath water will be monitored to ensure that it is not hot enough to damage tissue.

AEB

Cr level of 4.01 and shortness of breath.

         

Hgb of 9.5 and Hct of 29.1.


 

*I = Implementation.  Check those interventions/actions/orders that were implemented.

NEEDS References

               

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