Actual problem:

1. Nursing Diagnosis: Excess Fluid Volume related to compromised regulatory mechanisms secondary to renal dysfunction: Oliguric phase as evidenced by:

Swelling in the arms(edema)

Decreased mental and cognitive function
Hypertension

GOALS OF CARE

After 8 hours of
nursing
interventions, client
will be able to:

INTERVENTION
INDEPENDENT
Assessment
1.Obtain patient history to
ascertain the probable cause
of the fluid disturbance

a. Have
decreased
excess body
fluid.

2.Auscultate for a third sound,

and assess for bounding
peripheral pulses

b. Have a
stable Blood
pressure of
140/90 to
90/60

3.Monitor input and output

closely

RATIONALE

EVALUATION

PATIENTS RESPONSE

1. Which can help to guide interventions.

May include increased fluids or sodium
intake, or compromised regulatory
mechanisms.

DONE

2. These are signs of fluid overload.

DONE

There was no presence of a third

sound in patients heart beat.
Carotid pulse was observably
pulsating and bounding.

3. Although overall fluid intake may be

adequate, shifting of fluid out of the
intravascular to the extravascular spaces
may result in dehydration. The risk of this
occurring increases when diuretics are
given.

DONE

Patient manifested fluid volume

deficit.

Folks were able to give information

about the probable cause of the fuild
disturbance: Hypertension and
Acute Kidney Failure.

Therapeutic
1.Reduce constriction of
vessels (use appropriate
garments, avoid crossing of
legs or ankles)

1.To prevent venous pooling

DONE

There were no tight garments, no

crossing of legs by the patient.

2.Assist with repositioning

every 2 hours if patient is not
mobile

2.To prevent fluid accumulation in

dependent areas

DONE

Patient was turned every 2 hours.

3.Elevate edematous
extremities

3.To increase venous return and, in turn,

decrease edema

DONE

Clients arms were elevated by

putting a pillow under each arm

2.Nursing Diagnosis: Self-care deficit related to energy deficit as evidenced by:

Inability to feed self independently
Inability to dress self independently
Inability to bathe and groom self independently
Inability to perform toileting tasks independently
Inability to transfer and ambulate independently
Goals of care
Within 8 hours of nursing
intervention client will be able
to:
a) Have a proper and
good hygiene for
health promotion and
recovery

Interventions
INDEPENDENT
Assessment
1. Assess related factors
such as: current level
of self-care
2. Assess clients range
of motion and activity

Rationale

Evaluation

Patients Response

1. This will be a basis for

further interventions for
the client care.

DONE

Client showed decreased level

of independence. Needs help
in almost every activity of daily
living

2. To promote muscular
recovery and motor
activity

DONE

Clients range of motion was

very limited.

DONE

Client was unable to perform

active range of motion but was
able to perform passive range
of motion.

DONE

Client was able to receive

mouth care.

Therapeutic:
1. Assist patient in
passive and active
range of motion

1. To promote muscular
recovery and motor
activity

2. Apply mouth care to

the patient.

2. To prevent bacterial
formation in oral cavity.

Potential problem:
3. Risk for infection related to high glucose levels & alterations in circulation as evidenced by:
High glucose levels
Diagnosed of DM II
Increased WBC count
Decreased sensation on extremities
GOALS OF CARE
INTERVENTION
RATIONALE
INDEPENDENT
Assessment
1. Observe for signs of
1. Patient may be admitted with
infection and
infection which may develop a
inflammation (fever,
flushed appearance,
nosocomial infection
cloudy urine)

EVALUATION

DONE

PATIENTS RESPONSE

Client showed increase WBC and

segmenters on the CBC, showing an
infection.

Therapeutic:
1. Reduces risk of crosscontamination

DONE

2. Provide
catheter/perianal care.

2. Minimizes risk for UTI. Patients

with urinary catheters are prone to
urinary tract infections.

DONE

Clients urinary bag were drained hourly

to prevent ascending infection

3. Provide conscientious
skin care; gently
massage bony areas;
keep linens dry and
wrinkle free

3. Peripheral circulation may be

impaired, placing patient at
increased risk for skin breakdown
and infection

DONE

Clients skin was clean, dry, and did not

have any breaks in the continuity of the
skin

DONE

Clients medications were given

1. Promote good hand

washing by the staff
and patient

COLLABORATIVE
1. Take prophylactic
medications prescribed
by the doctor

1. In doing this, the client will be able

to alleviate his infection