Client name: Mrs. Chan Age/ sex: 48/F Medical diagnosis: Fluid overload, decreased TK output and decreased Hb Assessment date: 25-11-2012 Diagnostic statement (PES): Excess fluid volume related to compromised regulatory mechanism secondary to end-stage renal failure as evidence by peripheral edema and patient’s weight gained from 69.8kg to 73.6kg within 4 days.
Goals & Expected Outcomes
Methods of Evaluation
1. The client claimed her weight started to gain quickly 2 weeks before admission.
2. The client reported of taut and shiny skin appeared on the limbs and face.
3. The client complained on decreasing urinary output 2 weeks before admission.
4. The client complained of increasing SOB and orthopnoea
1. Pressing thumb for 5s into the limbs’ skin and removed quickly resulted in pitting and graded at +1.
2. The client’s weight gained from 69.8kg to 73.6kg from 25/11/2012 to 29/11/2012.
3. Reduced CAPD output was noted.
4. Shifting dullness on abdomen was noted.
Dysfunctional health pattern:
Nutrition and Metabolism
Excess fluid volume
Etiology: related to compromised regulatory mechanism secondary to end-stage renal failure
Signs & symptoms :
1. Client’s weight gained from 69.8kg to 73.6kg within 4 days.
2. Peripheral edema graded at +1.
The client will exhibit decreased edema on peripheral.
1. The client can regain fluid balance as evidenced by weight loss accessed by3/12/2012
2. The client will be able to verbalize the restricted amount of necessary dietary like sodium and fluid as prescribed by 3/12/2012.
3. The client will be able to demonstrate 1 method to access edema by 3/12/2012
4. The client will demonstrate 2 method to help reduce edema by 3/12/2012 1. Ongoing assessments
a) Record 24hrs intake and output balance.
b) Weigh at 0600 and 1800 daily
2. Therapeutic interventions
a) Introduce the needs for low sodium diet and the lower the fluid intake less than 800ml
b) Apply stockings while lying down and check extremities frequently for adequate circulation.
c) Advise the client to elevate her feet when sitting
3. Education for client and caregivers
a) Plan ROM exercise for all extremities every 4h
b) Teach pressing thumb for 5s into the skin and grading if appear in pitting.
c) Educate the sign and syndromes of edema.
d) Teach to avoid canned and frozen food and cook without salt and use spices to add flavour. 1a) Weight client daily can monitor trends to evaluate interventions.( Lewis& Sharon Mantik., 2011) b) Monitor IO chat can determine effect of treatment on kidney function( Lewis& Sharon Mantik., 2011)
2a) High-sodium intake leads to increase water retention(Carpenito, L. J., 2010) b) Compression stockings increase venous return and reduce venous pooling. (Carpenito, L. J., 2010) c) This prevent fluid accumulation in the lower extremities. (Gulamick & Myers, 2007)
3a) Contracting skeletal muscles increase lymph flow and reduce edema. (Carpenito, L. J., 2010) b&c) Client and caregiver can help monitor and control fluid overload ( Lewis& Sharon Mantik., 2011) d) Restrict the sodium intake can decrease the feeling of thirst to drink water. ( Gulamick & Myers, 2007)
1. Keep checking on the change of client’s weight.
2. Assess the client’s edema condition every day by pressing.
3. Ask the client to demonstrate the method for accessing and reducing edema.
4. Ask the client to record the menu eaten for checking the eating habits.
5. Ask the client to verbalize syndromes of edema.