NURSING CARE PLAN

Problem no.

ASSESSMENTNURSING

DIAGNOSISSCIENTIFIC RATIONALE

OBJECTIVENURSING

INTERVENTIONSCIENFIC

RATIONALEEVALUATION

Subjective cues:

The client verbalized, “medyo namamaga yung paa ko.”

Objective cues:

Bipedal edema

+2 pitting edema

Weight gain +3

proteinuria UO = 400 ml

Vasospasm

Interstitial effects

Diffusion of fluidfrom

bloodstreaminto interstitial

tissue

EDEMA

After 4 hours of nursing intervention, client’s edema will be reduce from +2 to +1.

Assess fluid status:a. Daily weightb. Intake and output

balancec. Skin turgor and

presence of edemad. Blood pressure,

pulse rate, and rhythm

e. Respiratory rate and effort

Instruct client to reduce sodium intake and to increase water intake

Elevate edematous extremities.

Change position frequently.

Provide cold compress

Assessment provides baseline and ongoing database for monitoring changes and evaluating interventions.

To help reduce extracellular volume and drinking lots of water actually reduces retention.

To increase venous return and, in turn, decrease edema.

To prevent fluid accumulation in dependent areas.

To reduce swelling

Provide cool and dry environment

Refer accordingly

To reduce swelling and avoids worsening because heat aggravates edema.

For further management and evaluation