Kong, Michael Robert NCP

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent
SUBJECTIVE: Fluid Volume Renal failure After 8 hours of Goal met,
“Namamanas excess r/t nursing • Record accurate • Accurate I&O is patient has
ako at ang hina Compromised intervention, the intake and output necessary for displayed
ng katawan ko” regulatory Decrease blood patient will (I&O). determining renal appropriate
(I have edema and mechanism flow to kidneys display function and fluid urinary output
I feel very weak) (renal failure) appropriate replacement needs with specific
as verbalized by urinary output and reducing risk of gravity/laborato
the patient Decrease with specific fluid overload ry studies near
perfusion in gravity/laborator normal; stable
kidney y studies near • Weigh daily at • Daily body weight, vital
OBJECTIVE: normal; stable same time of day, on weight is best signs within
weight, vital same scale, with monitor of fluid patient’s
• Venous Decrease signs within same equipment and status normal range;
distension urinary output patient’s normal clothing and absence of
• Generaliz range; and edema.
ed edema absence of • Assess skin,
• Patient Water retention edema. face, dependent • Edema occurs
reports of areas for edema primarily in
Fatigue, dependent tissues
weakness, Fluid volumes of the body, e.g.,
and malaise excess hands, feet,
• V/S taken lumbosacral area.
as follows Patient can gain up
to 10 lb (4.5 kg) of
T: 35˚C fluid before pitting
P: 50 edema is detected
R: 13 • Plan oral fluid
BP: 130/90 replacement with • Helps avoid
patient, within periods without
multiple restrictions fluids, minimizes
boredom of limited
choices, and
reduces sense of
Kong, Michael Robert NCP

Collaborative deprivation and

thirst
• Administer/restric
t fluids as indicated.
• Fluid
management is
usually calculated to
replace output from
all sources plus
• Administer estimated insensible
medication as losses
indicated
Diuretics, e.g., • Given early in
furosemide (Lasix), oliguric phase of
mannitol (Osmitrol) Renal Failure in an
effort to convert to
nonoliguric phase,
flush the tubular
lumen of debris,
reduce
hyperkalemia, and
• Antihypertensive promote adequate
s, e.g., clonidine urine volume.
(Catapres)
• May be given to
treat hypertension
by counteracting
effects of decreased
renal blood flow
and/or circulating
volume overload