Concept Care Map
Student: __Carlyn Romero____________
Client’s initials, age, gender: _RL, 89, F______
Occupation: _______________________________
Culture: ___Irish______
Date of admission: ___11/14/21__ Religion: __Catholic
( 1) Risk for electrolyte imbalance
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 excessive fluid volume
 increased sodium intake
 orthopnea
BP alteration
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Diet:___Sodium Restricted 2g_____
Allergies: ___Penicillins__
Med-Surg history: _______________________________________________________
( 5 ) Activity Intolerance
(7) Risk for relocation stress syndrome
 immobility
 generalized leg weakness
 physical deconditioning
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 concern about relocation
 increase in illness
 increase in physical symptoms
 preoccupation re: social life
 significant environmental change
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( 2) Risk for infection
(8 ) Anxiety
 alteration in skin integrity
 stasis of body fluid
 wounds in leg
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 fidgeting
 worried about life changing event
 hypervigilance
 nervous about dx
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Reason for seeking healthcare
Excess Fluid Volume
(3) Ineffective Health Management
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 Minimizes symptoms
 doesn’t admit impact of disease on life
 refusal of healthcare advice
 inappropriate affect
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 refuses to go to SAR
 family conflict
wants to live alone
 difficulty with regimen
(4 ) Disturbed sleep pattern
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(9 ) Ineffective Denial
 physical discomfort
 immobilization
disruption caused by sleep partner
 alteration in sleep pattern
 environmental barrier
jgk/2005
(6 ) Risk for falls
Not sure
 impaired mobility
 use of one crutch
 sleeplessness
 difficulty with gait
decrease in lower ext. strength
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Nursing Care Plan
Student: ___Carlyn Romero______ Client::______ Diagnosis:__Edema of Bilateral legs_______
Nursing Diagnosis: Excess fluid volume related to excessive sodium intake as evidenced by edema in bilateral legs.
Behavioral Outcomes (formulate by what is to be accomplished on date of care)
Client will:
1) Patient will have no evidence of edema in lower extremities within 72 hours of hospitalization.
2) Patient will maintain a HR of 60-100 beats/min.
Overall Goal (upon discharge improvement/resolution of nursing diagnosis will be evidenced by)
Client will: The patient will explain measures that can be taken to treat and prevent fluid volume excess.
Nursing Interventions
1.
Obtain patient history to ascertain the probable cause
of the fluid disturbance.
2.
Auscultate for a third sound and assess for bounding
peripheral pulses.
3.
Scientific Rationales
1.
This will help to guide interventions
2.
These are signs of fluid overload.
3.
To help reduce extracellular volume. For some patients, fluids
may need to be restricted to 100 ml per day.
4.
Elevation increases venous return to the heart and, in turn,
decreases edema. Edematous skin is more susceptible to
injury.
5.
Information is key to managing problems.
6.
These aids help promote venous return and minimize fluid
accumulation in the extremities.
Institute/instruct patient regarding fluid restrictions as
appropriate.
4.
Elevate edematous extremities, and handle with care.
5.
Educate patient and family members regarding fluid
volume excess and its causes.
6.
Explain the need to use antiembolic stockings or
bandages, as ordered.
Evaluation of Outcomes
1)
The patient has been hospitalized for 48 hours, the edema in the bilateral extremities has reduced tremendously, will evaluate
again in 24 hrs.
2)
On assessment, patient’s HR was 99. Has maintained a stable HR throughout the shift.
Evaluation of Goal
Patient stated she will take her medications as directed, maintain a healthy weight, avoid foods high in sodium, & monitor her
fluid intake.
jgk/2005