Medical Diagnosis: Renal Failure

Problem: Fluid Volume Excess RT Decreased Glomerular Filtration Rate and Sodium Retention

Assessment Nursing Diagnosis Scientific Explanation Planning Interventions Rationale Evaluation

Subjective: (none) Fluid Volume Excess Renal disorder Short Term: 1. Establish rapport 1. To assess Short Term:
R/T decrease impairs glomerular After 4-8 hours of precipitating and The patient shall have
Objective: Glomerular filtration filtration that nursing interventions, causative factors. demonstrated
Patient manifested: Rate and sodium resulted to fluid patient will behaviors to monitor
 Edema retention overload. With fluid demonstrate 2. Monitor and 2. To obtain fluid status and
 Hypertension volume excess, behaviors to monitor record vital signs baseline data reduce recurrence of
 Weight gain hydrostatic pressure fluid status and fluid excess
 Pulmonary is higher than the reduce recurrence of 3. Assess possible 3. To obtain
congestion (SOB, usual pushing excess fluid excess risk factors baseline data
DOB) fluids into the Long Term:
 Oliguria interstitial spaces. The patient shall have
 Distended jugular Since fluids are not Long Term: 4. Monitor and 4. To note for manifested stabilized
vein reabsorbed at the After 3 days of record vital signs. presence of fluid volume AEB
 Changes in venous end, fluid nursing intervention nausea and balance I & O, normal
mental status volume overloads the the patient will vomiting VS, stable weight, and
Patient may lymph system and manifest stabilize 5. Assess patient’s free from signs of
manifest: stays in the fluid volume AEB appetite 5. To prevent fluid edema.
interstitial spaces balance I & O, normal overload and
leading the patient to VS, stable weight, monitor intake
have edema, weight and free from signs of and output
gain, pulmonary edema.
congestion and HPN 6. Note 6. To monitor fluid
at the same time due amount/rate of retention and
to decrease GFR, fluid intake from evaluate degree
nephron all sources of excess
hyperthrophized
leading to decrease
ability of the kidney 7. Compare current 7. For presence of
to concentrate urine weight gain with crackles or
and impaired admission or congestion
excretion of fluid thus previous stated
leading to weight
oliguria/anuria. 8. Auscultate breath 8. To evaluate
sounds degree of excess

9. Record 9. To determine
occurrence of fluid retention
dyspnea
10. May indicate
10. Note presence of increase in fluid
edema. retention

11. Measure 11. May indicate

abdominal girth cerebral edema.
for changes.

12. Evaluate 12. To evaluate

mentation for degree of fluid
confusion and excess.
personality
changes.

13. Observe skin 13. To prevent

mucous pressure ulcers.
membrane.
14. To monitor fluid
14. Change position and electrolyte
of client timely. imbalances

15. To lessen fluid

15. Review lab data retention and
like BUN, overload.
Creatinine,
Serum
electrolyte.

16. Restrict sodium 16. To monitor

and fluid intake if kidney function
 indicated and fluid
retention.
17. Record I&O 17. Weight gain
accurately and indicates fluid
calculate fluid retention or
volume balance edema.

18. Weigh client 18. Weight gain may

indicate fluid
retention and
19. Encourage quiet, edema.
restful 19. To conserve
atmosphere. energy and lower
tissue oxygen
20. Promote overall demand.
health measure. 20. To promote
wellness.