Nursing Care Plan

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Medical Diagnoses: Excess Fluid Volume, Decreased urinary output

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

 

Pt’s daughter states that her mother has not urinated in a while.

 

 

Objective

     

No documented urinary output for the past 10 hours

     

Pt has taken in 1100 mL of IV fluids and 160 cc of PO fluids with no output.

     

Pt shows no signs of wetness or incontinence.



Problem

     

Excess fluid volume

     

     

     

     


Long Term:

 

Pt will remain free of complications such as: edema, decreased cardiac output, and JVD by discharge.

     

*Monitor client’s behavior for restlessness, anxiety, or confusion.

     

Rationale: “When excess fluid volume compromises cardiac output, the client may have cerebral tissue hypoxia and demonstrate restlessness and anxiety. When excess fluid volume results in hyponatremia, symptoms such as agitation, irritability, inappropriate behavior, confusion and seizures may occur.” (Ackley & Ladwig, 2008, p. 377).

 

     

     

     

     

ü       

 

     

     

R/T

 

Decreased urinary output

 

 

 

 

Short Term:

 

Pt will maintain urine output within 500 mL of intake within one day, by April 10, 2009.

 

*Provide scheduled rest periods.

 

Rationale: “Bed rest can induce dieresis related to diminished peripheral venous pooling, resulting in increased intravascular volume and GFR.” (Ackley & Ladwig, 2008, p. 377).

 

*Monitor intake and output.

 

Rationale: “Accurately measuring intake and output is vital for the client with fluid volume overload.” (Ackley & Ladwig, 2008, p. 377).

 

 

 

 

 

 

 

 

 

AEB

 

No urinary output documented for the past 10 hours

 

IV intake of 1100 mL and PO fluids of 160 cc without any urinary output.

 

 

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

 

References

 

Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed.). St. Louis: Mosby Elsevier.



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