This is a nursing care
plan sample about excess fluid volume of Mrs. Moto, 35 years old, a vlogger and
a podcaster, diagnosed with acute renal failure. Mrs. Moto is very workaholic
and sometimes she even forgot to fix herself because of her work. She hyper
runs and jumps if she needs to. Her vlogs and podcasts are not just work for
money but work with passion. One day, her cameraman saw something different
from her feet and told her if she was okay. Mrs. Moto was afraid of what she
saw.
Assessment:
Subjective: "Help please, what happen to my feet?" as verbalized by the patient.
Objectives:
- Edema on lower
and upper peripheral part of the body
- Taut, shiny skin
- Weight gain
Diagnosis:
Excess fluid volume
related to compromised regulatory mechanisms secondary to: acute renal
failure.
Planning:
After 8 hours of nursing
intervention, the patient will exhibit decreased edema on lower peripheral
part of the body. The patient will enumerate the causative factors of excess
fluid volume and will enumerate methods of preventing edema.
Interventions:
- Identify contributing
and causative factors about Mrs. Moto's situation.
- Reduce or eliminate causative and contributing factors.
- Assess Mrs. Moto's dietary intake and her habits that may contribute to fluid
retention. Be specific; record her daily and weekly intake of food and fluids.
Assess Mrs. Moto's weekly diet for inadequate protein or excessive sodium
intake. Discuss likes and dislikes of foods that provide protein.
- Teach Mrs. Moto to plan a weekly menu that provides protein at an affordable
price. Teach her to decrease salt intake. Read labels for sodium content. Avoid
convenience and canned and frozen foods. Cook without salt; use spices like
lemon, basil, tarragon, mint to add flavor. Use vinegar in place of salt
to flavor soups, stews, etc. Ascertain whether Mrs. Moto may use salt
substitute.
- Assess for evidence of dependent venous pooling or venous stasis. Encourage
alternating periods of horizontal rest with legs elevated with vertical
activity or standing; this may be contraindicated in congestive heart failure.
Keep the edematous extremity elevated above the level of the heart whenever
possible (unless contraindicated by heart failure).
- Elevate Mrs. Moto's legs whenever possible, using pillows under them but
avoid pressure points, especially behind the knees. Discourage leg and ankle
crossing. Reduce constriction of vessels.
- Assess clothing for proper fit and constrictive areas. Instruct Mrs. Moto to
avoid panty-girdles/garters, knee-high stockings, and leg crossing and to
practice elevating her legs when possible. Consider using anti-embolism
stockings or Ace bandages; measure her legs carefully for stockings/support
hose. Measure the circumference of her calf and her thigh. Consider both
measurements when choosing stockings, matching measurements with a size
requirement chart that accompanies the stockings. Apply stockings while Mrs.
Moto is lying down like in the morning before arising. Check her extremities
frequently for adequate circulation and evidence of constrictive areas.
- Assess for venous pressure points associated with casts, bandages, and tight
stockings. Observe circulation at edges of casts, bandages, and stockings. For
casts, insert soft material to cushion pressure points at the edges. Check
circulation frequently. Shift body weight in the cast to redistribute weight
within, unless contraindicated. Encourage Mrs. Moto to do this every
15 to 30 minutes while awake to prevent venostasis. Encourage Mrs. Moto to
wiggle her toes and isometric exercise of unaffected muscles within the cast.
If she cannot do this alone, assist her at least hourly to shift body
weight.
See Impaired Physical Mobility.
- Keep her extremity elevated on pillows. If the edema is marked, the arm
should be elevated but not in adduction, be careful because this position may
constrict her axilla. Her elbow should be higher than her shoulder. Her hand
should be higher than her elbow. Measure Mrs. Moto's blood pressure in her
unaffected arm. Do not give injections or start IV fluids in her affected arm.
Protect her affected limb from injury. Teach Mrs. Moto to avoid using
strong detergents, carrying heavy bags, holding cigarettes, injuring cuticles
or hangnails, reaching into hot ovens, wearing jewelry or a wristwatch, or
using Ace bandages. Advise Mrs. Moto to apply lanolin or a similar cream,
often daily, to prevent dry, flaky skin. Encourage Mrs. Moto to wear
a Medic-Alert tag engraved with Caution: lymphedema arm—no tests/no needle
injections. Caution Mrs. Moto to visit a physician if her arm becomes
red, swollen, or unusually hard.
- Inspect Mrs. Moto's skin for redness and blanching. Reduce pressure on her
skin areas; pad chairs; use knee-high stockings and footstools. Prevent dry
skin. Use soap sparingly. Rinse off soap completely. Use a lotion to moisten
skin.
- Initiate health teaching and referrals, as Indicated. Give clear verbal and
written instructions for all medications: what, when, how often, why, side affects;
pay special attention to drugs that directly influence fluid balance. Write
down instructions for diet, activity, and use of Ace bandages, stockings, and
so forth. Have Mrs. Moto demonstrate the instructions. With severe fluctuations
in edema, have her weigh herself every morning and before bedtime daily;
instruct the Mrs. Moto to keep a written record of weights. For less severe
illness, she may need to weigh herself only once daily and record the weight.
- Consider home care or visiting nurses referral to follow at home.
- Provide literature concerning low-salt diets;
consult with a dietitian if necessary.
Evaluation:
After 8 hours of nursing
intervention, the patient was exhibited decreased edema on lower
peripheral part of the body. The patient was enumerated the causative factors
of excess fluid volume and was enumerated methods of preventing edema.
For more samples of nursing care plan you are free to check it out in our NCP LIST page.
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