ASSESSMENT NURSING DIAGNOSIS SCIENTIFICEXPLANATION PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Excess fluid The body responds to this After nursing Vital signs taken and To have baseline After nursing
volume related to fluid shifts retaining sodium intervention the recorded. data for comparison intervention the
“Namamanas ang failure of regulatory and water to maintain client will reduce client’s fluid
buong katawan ng mechanism secondary intravascular volume leading recurrence of fluid Noted the amount To assess causative volume was
anak” to inflammation of to excess fluid intake. excess and return /rate of fluid intake or precipitating stabilized as
glomerular membrane to usual weight from all sources. factors evidence by I/O ,
Objective inhibiting filtration. with no evidence of vital signs within
- Medical and Surgical edema Weigh daily or on client’s normal
Weight: from 17kg Textbook- regular schedule as Provides limits stable
to 27 kg ordered. comparative weight and free
baseline of sign signs of
BP: 100/70 Compared current edema
weight with
RR:25 admission and To evaluate degree
previously recorded of excess
PR:95
Measured abdominal
Intake: 120 circumference To indicate changes
in fluid retention or
Output: 90 edema
Recorded I/O
Edema upon accurately To promote
inspection and mobilization/
palpation elimination of
excess fluid
Restricted the
sodium and fluid To promote
intake as doctor mobilization/
ordered elimination of
excess fluid
 NAME ACTION AND INDICATION SIDE EFFECTS / CONTRAINDICATION NURSING MONITORING
CALASSIFICATION ADVERSE EFFECT RESPONSIBILITY PARAMETERS

Generic name: Action Treatment for acute CNS: vetigo, Patients with To prevent nocturia , May increase
pulmonary edema headache dizziness, hypersensitivity to give P.O and I.M.. cholesterol, glucose
Furosemide A potent loop diuretic paresthesia , drugs and those with preparation in the and and uric acid
(frusemide) that inhibits sodium For hypertension and weakness anuria. morning. levels.
and chloride edema restlessness, fever
Barand name: reabsorption at the Patients with cirrhosis Monitor fluid intake May decrease calcium,
proximal and distal CV: orthostatic and allergic to and output and hemoglobin,
Apo-Furosemide tubules and the hypotension sulfonamides electrolyte magnesium, potassium
ascending loop of and sodium levels
Furosemide Special Henle GI: abdominal During pregnancy If oliguria or
IV discomfort and pain azotemia develops or May decrease
Classification diarrhea, anorexia, increase, drug may be granulocytr, platelet
Furoside nausea, vomiting and stopped. and WBC counts
Diuretics pancreatitis
Novosemide Watch for signs of
GU: nocturia, hypokalemia, such as
Dosage/ Route polyuria, frequent muscle weakness and
/Frequency frequent urination, cramps
olyguria
Infants and children: Monitor uric acid
2 mg/kg P.O daily, Skin: Dermatitis, level , especially in
increased by 1 to 2 puspura, patients with severe
mg/ kg in 6 to 8 hrs if photosensitivity heart failure.
needed carefully reaction
adjusted up to 6 mg/ Monitor glucose level
kg daily if needed in diabetic patients
Drug may not be well
absorbed orally in
patient with severe
heart failure I.V. even
if patient