Nursing Care Plan

Nursing Care Plan
Client name: Mrs. Chan   Age/ sex: 48/F     Medical diagnosis: Fluid overload, decreased TK output and decreased Hb                               Assessment date: 25-11-2012   Diagnostic statement (PES): Excess fluid volume related to compromised regulatory mechanism secondary to end-stage renal failure as evidence by peripheral edema and patient’s weight gained from 69.8kg to 73.6kg within 4 days.
|Assessment                                           |Nursing Diagnosis         |Goals & Expected Outcomes             |Nursing Interventions                         |Rationales                                 |Methods of Evaluation     |
|Subjective data:                                     |Problem:                   |Goals:                                 |Ongoing assessments                           |1a) Weight client daily can monitor trends|1. Keep checking on the   |
|The client claimed her weight started to gain       |Excess fluid volume       |The client will exhibit decreased     |Record 24hrs intake and output balance.       |to evaluate interventions.( Lewis& Sharon |change of client’s weight.|
|quickly 2 weeks before admission.                   |                           |edema on peripheral.                   |Weigh at 0600 and 1800 daily                 |Mantik., 2011)                             |                           |
|                                                     |Etiology:                 |                                       |                                             |b) Monitor IO chat can determine effect of|2. Assess the client’s     |
|The client reported of taut and shiny skin appeared |related to compromised     |                                       |Therapeutic interventions                     |treatment on kidney function( Lewis&       |edema condition every day |
|on the limbs and face.                               |regulatory mechanism       |Expected outcomes:                     |Introduce the needs for low...