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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