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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
“I was feeling short of breath. It
didn’t get better when I sat down.
I had a pressure-pain in the middle of my chest and I got scared.”
Objective:
BNP:
585
Troponin:
0.12
Bilateral 3+ pitting edema
Diminished pedal pulses 1+ bilaterally
Crackles heard bilaterally in lung bases, elevated
BP, oliguria, hyperventilation, PaO2 86%
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Problem:
Fluid volume excess
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Long Term:
Client will remain free of edema, effusion, and anasarca by [Date] at 16:00.
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-Monitor intake and output throughout shift
on [date], note trends reflecting decreasing urine output in relation to
overload. Accurately measuring intake
and output is vital for the client with fluid volume overload (Ackley et al., 2008).
-Provide a restricted sodium diet as appropriate
on [date]. Restricting sodium
in the diet will favor the renal excretion of excess fluid (Kasper et. al, 2005)
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Evaluation of this goal is set for 16:00, [date]. Client has bilateral pitting
edema and adventitious breath sounds.
No progress towards goal made. Continued
intervention and evaluation required.
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Monitored intake and output.
Provided a sodium restricted diet.
No progress towards goal. Continuance
of the interventions warranted along with further evaluation.
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R/T:
compromised regulatory mechanism secondary to congestive heart failure
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Short Term:
Client will explain measures that can be taken to treat or prevent excess fluid
volume, especially dietary restrictions and medication schedules.
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By shift’s end on [date]:
-Assess client’s current level of knowledge r/t excess fluid volume treatments and
s/s
-Seek teachable moments to encourage health promotion.
The provision of information should not be restricted to just treatment information
but also any information that prepares the client to manage health-related issues
(Timmons, et. al 2006)
- Teach the importance of fluid and sodium restrictions.
Education programs based
on empowerment, client participation, and adult learning principles have demonstrated
effectiveness (Kennedy, et. al, 2003).
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Client explained measures to prevent and treat excess fluid volume including dietary
restrictions and medication regimen at 13:03 on [date].
Goal achieved.
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At 11:00 on [date] assessed client’s current level of knowledge related
to dietary measures and medications to prevent excess fluid volume and s/s of fluid
volume excess.
Sought teachable moments to encourage health promotion, provided education on nutrition
and easy meals to freeze and make at home.
Taught client the generalized and localized signs and symptoms of fluid volume excess
to monitor for both within the hospital and at home.
Goal achieved.
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