Assessment
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Nursing DX/Clinical Problem
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Client Goals/Desired Outcomes/Objectives
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Nursing Interventions/Actions/Orders and Rationale
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*I
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Evaluation
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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.
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Problem
Excess fluid volume
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Long Term:
Pt will remain free of complications such as: edema, decreased cardiac output, and
JVD by discharge.
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*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).
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ü
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R/T
Decreased urinary output
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Short Term:
Pt will maintain urine output within 500 mL of intake within one day, by April 10,
2009.
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*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).
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