Assessment Data

Nursing Diagnosis

   Desired        Outcomes

                       Interventions/Rationale

      Evaluation

 (List the things your patient has which make you suspect he/she is overhydrated) 

Objective: 
Weight gain in past month 
Edema 
Tight, shinny skin 
Crackles in lungs 
Decreased urine output 
Na level 134 
Hct level below 35 

Subjective: 
"My feet and legs are so swollen" 
"I just can't breath if I'm flat in bed"

Fluid volume excess RT water retention secondary to decreased renal perfusion and cardiac output

(AEB 15 lb weight gain in past month, 
Edema, 
Tight, shinny skin 
Crackles in lungs 
Decreased urine output 
Na level 134 
Hct level below 35 )

Patient will not have fluid volume excess

Outcome Criteria: 

1.Client's weight will be WNL for Ideal Body Weight (give numbers).

2.Client will verbalize ability to breathe comfortably.

3.Lungs will be clear

4.Vital Signs will Be WNL

5.Relevant lab values (Sodium, Hct) will be WNL.Na 135-145) etc. 

6.Urine will be clear yellow with output >30cc/hr

7.Intake will not be greater than output

8.No evidence of skin breakdown.

Restrict fluids to 350 cc per shift. 
R: Excessive fluids will worsen client's condition. (Sparks, 110) 

Weigh client at same time each day, using same scale. 

R:  Provides baseline and continuing database for monitoring changes and evaluating interventions.  (Brunner, 1039) 

Monitor extremities for venous return (check pulses and capillary refill) q shift. 
R:  Decrease in venous blood flow results in an increase in venous pressure, a rise in capillary hydrostatic pressure, a net filtration of fluid out of the capillaries, and thus edema. (Brunner, 625) 

 
Administer diuretics (Lasix) as prescribed.

R:  To increase excretion of water. (Ulrich, 508) 

Help client into a position that aids breathing, such as Fowler's or Semi-Fowler's. 
R:  To increase chest expansion and improve ventilation. (Sparks, 110) 

Encourage client to cough and deep breathe q2h. 
R: To prevent pulmonary complications. (Sparks, 110) 

Auscultate lung sounds q 4 hours. Monitor Pulse Ox Q 4 hours, Monitor CXR results, as performed. 
R:  To look for pulmonary vascular congestion, pleural effusion, or pleural edema. (Ulrich, 508) 

Assess vital signs q4h. 

Assess lab values q shift. 

Administer vasodilators, as ordered.

R:  To improve renal blood flow. (Reduced renal perfusion stimulates the renin-angiotensin-aldosterone mechanism) (Ulrich, 508)

Encourage client to restrict Na intake. 

R:  Restriction of NA intake reduces the amount of Na that passes through the kidney and is reabsorbed. This results in decreased retention of water. (Ulrich, 37) 

Test urine specific gravity q8h. 
R:  High specific gravity indicates fluid retention.  Fluid overload may alter electrolyte values. (Sparks, 110)

Examine skin q8h for signs of bruising or other discoloration. 

R:  Edema may cause decreased tissue perfusion with skin changes. (Sparks, 108) 

Reposition client q2h. Skin care q4h. (Cleanse wound with saline, dry, apply polysporin and dry gauze dressing.) 
R:  To prevent further skin breakdown. (Sparks, 108) 

1.Clients weight was stable at 145 lbs.

2.Client stated she could breathe better

3.Lungs had decreased crackles

4.Vital signs were T 98.6 P 87 R 24 B/P 134/86

5.Na was 135 Hct was 36

6.Urine was clear yellow with output over 30 cc/hr

7.Intake was 350 cc this shift with output of 475 = Negative fluid balance of 125 cc this shift.

8.There was no skin breakdown

Assessment

(Data Related to Nursing Diagnosis)

Nursing Diagnosis

Desired Outcomes

Nursing Interventions/Rationale

Evaluation

What Objective and Subjective Data lead you to this one diagnosis? 

Objective: 

CVA with Left Sided Paralysis 

Diminished Gag Reflex 

Difficulty Swallowing Liquids 

 
 

Subjective (from patient or family) 

" Mom chokes every time she eats". 

Risk for/Potential for Injury (Aspiration) related to diminished gag reflex and impaired swallowing ability

  (Should be broad statements which solve the Problem part of the Nursing Diagnosis Statement.) 

Patient will not have injury related to aspiration AEB

Outcome Criteria: Specific and observable things which allow an observer to determine if the patient met the goal 
 

1.Patient will have no choking or aspiration episodes while eating. 

etc.

Interventions should be things that you do to assist the patient in reaching the goal. They should be focused on addressing the cause of the problem (the related to part of the nursing diagnosis statement)

 1.Place patient on side or with HOB up to avoid aspiration of mucous. 

 R: Keeping the HOB elevated and the patient on their side decreases the chances of aspiration. (Sparks, p115)

etc.

Evaluate based on the patients progress towards each of the outcome Criteria 

1.Met. Patient did not have problems with choking during my shift. 

etc.