- Excess Fluid Volume related to sodium retention as manifested by presence of edema in both lower extremities
- Ineffective Health Maintenance related to conflict between cultural beliefs and health practices evidenced by failure to take action that prevents health problem
- Risk for Impaired Skin Integrity related to Edema as evidenced by tight and shiny skin
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: -Difficulty breathing -Anxiety -Weight gain or swelling Objective Data: -Shortness of breath (orthopnea, dyspnea, increased respiratory rate) -Adventitious breath sounds (rales or crackles) -Abnormal electrolyte levels -High blood pressure -Edema -Change in mental status -Jugular vein distention -Oliguria -Tachycardia -Pulmonary congestion/edema | Excess Fluid Volume related to sodium retention as manifested by presence of edema in both lower extremities | The patient will demonstrate a reduction of edema through physical examination The patient will maintain clear lung sounds and the absence of symptoms of respiratory distress | 1. Administer medications. Diuretics are provided to patients with edema and excess fluid accumulation to aid in fluid elimination by increasing urine output. 2. Restrict fluids as ordered. Fluid restriction can decrease cardiac workload in patients with edema and fluid overload. Patients with congestive heart failure, for example, are often on fluid restrictions. 3. Encourage a low-sodium diet. Educate patients that large amounts of sodium cause the body to retain water in an attempt to dilute it which causes fluid overload. Instruct on ways to lower sodium intake. 4. Weigh daily. Daily weights can assess the effectiveness of diuretic therapy. Educate patients with conditions such as CHF that if they notice a weight gain of 5 lbs in a week or 2 lbs overnight, they should contact their doctor. | The patient demonstrated a reduction of edema through physical examination The patient maintained clear lung sounds and the absence of symptoms of respiratory distress |
| Subjective Data: -Expressed disinterest in improving health -Expressed lack of knowledge or knowing where to start -Describes barriers to effective health maintenance Objective Data: -Failure to take action that prevents health problem -Inadequate commitment to a plan of action -Inadequate interest in improving health | Ineffective Health Maintenance related to conflict between cultural beliefs and health practices evidenced by failure to take action that prevents health problem | The patient will verbalize understanding of health maintenance goals and adhere to the treatment regimen The patient will demonstrate an improvement in health conditions and in turn, edema | 1. Involve support systems. If available, involve family and other support persons in understanding the causes and prevention of edema. 2. Ensure the patient understands their disease process. Edema is often a result of uncontrolled medical conditions such as cirrhosis, kidney disease, or heart failure. Educate the patient on the importance of managing these chronic conditions. 3. Refer to appropriate community and social services. The involvement of a social worker or case manager may be necessary to provide routine follow-up. Disease management programs can provide ongoing education and monitoring to reduce readmissions and produce better health outcomes. | -The patient verbalized understanding of health maintenance goals and adhere to the treatment regimen -The patient demonstrated improvement in health conditions and in turn, edema |
| Subjective Data: -Pain -Itching -Numbness to affected and surrounding skin Objective Data: -Edema -Inflammatory process -Decreased tissue perfusion -Alteration in skin turgor | Risk for Impaired Skin Integrity related to Edema as evidenced by tight and shiny skin | 1. Keep the skin clean and dry. To reduce the risk of skin damage, the affected area must be kept clean and dry. Provide daily skin hygiene to patients who are bed bound and incontinence care as necessary. 2. Elevate edematous extremities. Elevate edematous extremities above the level of the heart several times per day to ease swelling. 3. Apply compression stockings. Compression stockings can prevent fluid build-up in the legs and ankles and improve circulation. 4. Educate on positioning. Pregnancy, long periods of standing or sitting such as when flying can result in lower leg edema. Remind patients to elevate lower legs periodically. | Patient maintained intact skin integrity. Patient experienced timely healing of wounds without complications. Patient demonstrated effective wound care. Patient verbalized proper prevention of pressure injuries |