MAPANAO, Charie Mae D. BSN III-2 Patients name: Patient S.L.

Room #: 7
ASSESSMENT SUBJECTIVE: Adda ti manas ko as verbalized by the patient. OBJECTIVE: -with edema -blood pressure changes -with initial v/s of: BP: 140/80 mmHg Temp.: 36.7 C RR: 15 breaths/min. PR: 77 beats/min. DEPENDENT: -Administered medications COLLABORATIVE: -Assisted with procedures, as indicated -Assessed the patients edematous ankles/feet DIAGNOSIS -Excessive fluid volume r/t compromised regulatory mechanisms as manifested by edema PLANNING -After 8 hours of nursing intervention the client will stabilize fluid volume as evidence by free of signs of edema. INTERVENTIONS INDEPENDENT: -monitor clients vital signs.

Clinical Instructor: Mr. Alexander Bactad

RATIONALE

EVALUATION -Goal partially met. The

- To have a baseline data patient still with edema. of the clients condition to note any improvement of the clients condition. -to assess the how deep the edema is upon palpation.

-to improve clients condition

-to promote mobilization and elimination of excess fluid

-Set an appropriate rate of fluid intake

-to prevent peaks/valleys in fluid level and thirst.