What is the most appropriate nursing intervention in a patient with fluid overload and edema?

Scenario:

A 74 year old male presents to the ER with complaints of swelling in legs and feet, shortness of breath with any type of activity, non-radiating chest pain, increase cough, and the inability to sleep laying down at night. Pt states he has felt bad since Tuesday and today is Friday. He also states he has gained 7 pounds since he last weight on Tuesday. Pt currently weighs 210 lbs. Pt states he usually weighs around 200-203 lbs.  During history collection from pt, pt becomes short of breath and has to stop talking to catch his breath. Pt states that he takes Lasix 60mg PO BID but has not taken any since Monday because he wasn’t able to go to the pharmacy due to the snowstorm last week. Pt also takes Lisinopril 2.5 mg PO BID, Coreg 6.25mg PO Daily, Coumadin 5mg PO Daily (has a history of Atrial fibrillation), Potassium PO 20meq BID, and Multivitamin 1 Tab PO Daily. Vital Signs: BP 155/93, HR 95, O2 Sat 90% on 4L nasal cannula, Temp. 98.6. On assessment, 3+ pitting edema noted in lower extremities, bilateral crackles noted through out lung fields, hands and abdomen are swollen, and slight jugular distention noted. Lab and Diagnostic work shows: BNAT 1824, K+5.0, Creatinine 1.8, BUN 21, chest x-ray preliminary results show possible bilateral pleural effusions, and echo-cardiogram results show ejection fraction of 35%.

Nursing Diagnosis:

Subjective Data:

Objective Data:

Nursing Outcomes:

-Pt will have no evidence of edema in lower extremities within 48 hours of hospitalization.

Nursing Interventions:

– Pt will be placed on a 1500 ml fluid restricted diet per MD order and Intake and Output will be monitor and calculated after each shift.