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Example Nursing Diagnosis and Careplan For N205 Mini Careplanspote Ntial For

This nursing care plan addresses a patient with potential for fluid volume excess. The plan includes an assessment noting weight gain, edema, crackles in lungs, and decreased urine output. The nursing diagnosis is fluid volume excess related to decreased renal perfusion and cardiac output. Interventions include restricting fluids, administering diuretics, monitoring vital signs and labs, and skin care. The goals are for the patient's weight, lungs, labs, and skin to improve. After interventions the patient showed positive outcomes meeting the goals of the plan.

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Corina Radulescu
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38 views

Example Nursing Diagnosis and Careplan For N205 Mini Careplanspote Ntial For

This nursing care plan addresses a patient with potential for fluid volume excess. The plan includes an assessment noting weight gain, edema, crackles in lungs, and decreased urine output. The nursing diagnosis is fluid volume excess related to decreased renal perfusion and cardiac output. Interventions include restricting fluids, administering diuretics, monitoring vital signs and labs, and skin care. The goals are for the patient's weight, lungs, labs, and skin to improve. After interventions the patient showed positive outcomes meeting the goals of the plan.

Uploaded by

Corina Radulescu
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Example Nursing Diagnosis and Careplan for N205 Mini careplansPote ntial for

Injury (Apsiration)
Assessment Data Related toNursing DiagnosisN u r s i n g D i a g n o s i s G o a l N u r s i n g I n t e r v e n t i o n s E v a l u a t i o n

What Objective and SubjectiveData lead you to this one diagnosis. Objective: CVA with Left Sided ParalysisDiminished Gag ReflexDifficulty Swallowing Liquids Subjective (from patient or family)" Mom chokes every time sheeats". Potential for Injury (Aspiration)

related to dimminshed gag reflexand impaired swallowing ability Goal (Should be broad statements whichsolve the Problem part of the NursingDiagnosis Statement. )Patient will not have injury related toaspiration (10/20/95 2-10pm) Outcome Criteria

Specific and observable things whichallow an observer to determine if the patient met the goal1.Patient will have no chokingepisodes while eating.

2.
Patient color will remain cyanotic3.Patient lung sounds will remainclear 4.Patient CXR will show no signs of aspirationInterven

tions should be things thatyou do (either independently or dependently) to assist the patient inreaching the goal. They should befocused on addressing the cause of the problem (the related to part of the nursing diagnosis statement) Place patient on side or with HOB toavoid

aspiration of mucous.Feed patient liquids which have beenthickened, as thin liquids are morelikely to cause aspiration.Monitor lung sounds for signs of aspirationMonitor Lab and X-ray data for signs of aspiration.Evaluate based on the patients progresstowards each of theoutcome Criteria1.Patient did nothave problemswith

chokingduring my shift.2.Patient color was pink.3.Patient lungsounds remainedclear.4.You may or maynot have lab/X-raydata to report,depending on theday and what testshave beenordered.Goal Met, ContinuePlan. ALSO INCLUDE

Was this an appropriateNursing Dx for THISPATIENT? It may turnout that after you carefor the patient, youdiscover a higherpriority nursingdiagnosis.

Sample Nursing Careplan for

N205 : Fluid Volume Excess


Assessment DataNursing DiagnosisGoal: Patient will not havefluid volume excessI n t e r v e n t i o n s E v a l u a t i o n
(List the things your patienthas which make you

suspecthe/she is overhydrated)Objective:W eight gain in past monthEdemaTight, shinny skinCrackles in lungsDecreased urine output Na level 134Hct level below 35Subjective:"My feet and legs are soswollen""I just can't breath if I'm flatin bed"Fluid volume excess RT water retentionsecondary to

decreased renal perfusionand cardiac output Outcome Criteria: 1.Client's weight will beWNL for Ideal BodyWeight (give numbers).2.Client will verbalizeability to breathecomfortably.3.Lun gs will be clear 4.Vital Signs will Be WNL5.Relevant lab values(Sodium, Hct)

will beWNL ( Na 135-145) etc.6.Urine will be clear yellow with output>30cc/hr 7.Intake w ill not be greater than output8.No evidence of s kin breakdown.Restrict fluids to 350 cc per shift.SR: Excessive fluids will worsen client'scondition. (Sparks, 110)Weigh client at same time each day, using samescale. SR: Provides ba

seline and continuingdatabase for monitoring changes and evaluatinginterventions. (Brunner, 1039)Administer diuretics (Lasix) as prescribed. SR:To increase excretion of water. (Ulrich, 508)Help client into a position that aids breathing,such as Fowler's or Semi-Fowler's.SR: To increase chest expansion and improveventilation.

(Sparks, 110)Encourage client to cough and deep breathe q2h.SR: To prevent pulmonary complications. (Sparks, 110)Asculatate Lung Sounds q 4 hours. Monitor PulseOx Q 4 hours, Monitor CXR results, as performed.SR: To look for pulmonary vascular congestion, pleural peffusion, or pleural edema. (Ulrich, 508)Assess

vital signs q4h.Assess lab values q shift.Monitor extremities for venous return (check pulses and capillary refill) q shift.SR: Decrease in venous blood flow results in anincrease in venous pressure, a rise in capillaryhydrostatic pressure, a net filtration of fluid outof the capillaries, and thus edema. (Brunner,625)Adm

inister vasodilators, as ordered. SR: Toimprove renal blood flow. (Reduced renal1.Clients weightwa s stable at 145lbs.2.Client stated shecould breathe better 3 . L u n g s h a d decreasedcrackles4.Vit al signs were T98.6 P 87 R 24B/P 134/865 . N a w a s 1356.Hct was 3 6 7.Urine was clear yellow withoutput over

30cc/hr 8.Intake was 350 ccthis shift withoutput of 475 = Negative fluid balance of 125 ccthis shift.9.There was no skin breakdown

perfusion stimulates the renin-angiotensinaldosterone mechanism) (Ulrich, 508)Encourage

client to restrict Na intake.SR: Restriction of NA intake reduces theamount of Na that passes through the kidney and is reabsorbed. Thisresults in decreased retention of water. (Ulrich,37)Test urine specific gravity q8h.SR: High specific gravity indicates fluidretention. Fluid overload may alter

electrolytevalues. (Sparks, 110)Examine skin q8h for signs of bruising or other discoloration.SR: Ed ema may cause decreased tissue perfusionwith skin changes. (Sparks, 108)Skin care q4h. (Cleanse wound with saline, dry,apply polysporin and dry gauze dressing.)SR: To prevent further skin breakdown.

(Sparks,108)Reposition client q2h.

References Brunner, L.S. & Sudda rth, D.S. (1988). Medi cal-surgical nursing. Philadelphia: Lippinco tt.Sparks, S.M. (1993). Nursing diagnosis reference manual (2nd ed.). Springhouse,

PA: Springhouse Corporation.Ulrich, S.P., Canale, S.W., & Wendell, S.A. (1994). Medical- surgical nursing care planning guides (3rd ed.). Philadelphia:Saunders.

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