NCP-FLUID-VOLUME-EXCESS.docx - Ramos Ma. Teresa M....

Ramos, Ma. Teresa M.
Bachelor of Science in Nursing
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
Subjective:
"Hindi po ako
makagalaw ng
maayos at
nabibigatan po ako
sa aking sarili”
-As verbalized by
the client.
Objective:
Temp- 37.8 C
PR- 105 bpm
RR- 14 bpm
BP- 140/90 mmHg
 Weight gain
 Bipedal
edema
 Decreased
urine output
 Difficulty
walking
Fluid volume excess due
to compromised
regulatory mechanism
Scientific explanation:
Fluid Volume Excess
(FVE) , or hypervolemia ,
refers to
an isotonic expansion of
the ECF due to an
increase in total
body sodium content and
an increase in total body
water. This fluid overload
usually occurs from
compromised regulatory
mechanisms for sodium
and water as seen
commonly in heart
failure (CHF), kidney fail
ure, and liver failure.
.
Short Term:
After 2 hours of
Nursing Intervention,
the client will verbalize
understanding of
individual dietary/fluid
restrictions.