ASSESMENT Subjective: Objective: Edema Oliguria Weight gain Dyspnea Altered respiratory pattern Decrease hemoglobin and hematocrit

atocrit level Increase blood pressure Jugular vein distention Pulmonary congestion

NURSING DIAGNOSIS Fluid volume excess related to fluid retention secondary to chronic kidney disease as manifested by: Edema Oliguria Weight gain Dyspnea Altered respiratory pattern Decrease hemoglobin and hematocrit level Increase blood pressure Jugular vein distention Pulmonary congestion And patients verbalization of

RATIONALE Stress to kidney

OBJECTIVES Short Term: After 30 minutes to 1

NURSING INTERVENTIONS Independent: Position the patient that aids breathing such as Fowlers.

RATIONALE

EVALUATION Short Term:

To facilitate movement of diaphragm thus improving respiratory effort and to increase chest expansion.

After 1 hour of nursing interventions the patient is able to: Breathe comfortably. Have normal urine output of 30cc/hr. Demonstrate behavior such as maintaining fluid intake at 500ml/day

Decrease kidney function

hour of nursing

interventions the patient Fowlers or semi will be able to: Breathe comfortably. Have normal urine output of 30cc/hr. Demonstrate Monitor and record vital signs at least every 4 hours.

Deposition of immune complex fragments in the glomerolus

Changes may indicate may indicate fluid and electrolyte imbalances.

Proliferation of epithelial cell in the glomerolus

behavior such as maintaining fluid intake at 500ml/day and limit sodium

Measure and record

Provide comparative

and limit sodium intake (low salt low fat diet).

intake and output, weigh baseline and evaluates the patient and measure abdominal girth daily. effectiveness of diuretic therapy.

Decrease GFR

intake.

Decrease urine output Assess patient daily for Water retention Long Term: Third spacing of fluid Edema (wt. gain, jugular vein After 3 5 days of nursing interventions the patient will be able to: Elevate edematous To promote venous edema including ascites and dependent or sacral edema. Fluid overload or decrease osmotic pressure may result in edema, especially in dependent areas. Long Term: After 4 days of nursing interventions the patient is able to: Stabilize fluid volume as evidenced

distention, increase BP) Fluids goes to the lungs

Stabilize fluid volume as evidenced by balance intake

extremities and reposition the patient every 2 hours, inspect

return and to prevent skin breakdown.

by balance intake and output, free signs of edema. Laboratory values are within normal range/limits (hemoglobin=

and output, free signs skin for redness with of edema. each turn and institute measures as needed. Laboratory values are within normal range/limits. DOB Patient will be able to verbalize comfort. Encourage the patient to cough and deep breath every 2 to 4 hours. To prevent pulmonary complications.

Pleural effusion/ pulmonary congestion

hematocrit=

Dependent: Administer oxygen as ordered. To enhance arterial blood oxygenation.

Administer diuretics as ordered and record the result.

To promote fluid exertion.

Collaborative: Instruct the patient to limit fluid intake to 500ml/day and restrict sodium in the diet as ordered. To reduce excess fluid and prevent reaccumulation.

Monitor BUN, Crea, electrolyte, hemoglobin and hematocrit level.

BUN and Crea indicates renal function. Electrolyte, hemoglobin and hematocrit level indicate fluid status.

Reference: Nursing Diagnosis Reference Manual 6th Edition by Sparks and Taylor p.115-116

ASSESMENT Subjective:

NURSING DIAGNOSIS Anxiety related to situational crisis

RATIONALE Manifestation of signs and symptoms of the disease

OBJECTIVES Short Term: After 2-3 hours of nursing interventions the patient will

NURSING INTERVENTIONS Independent: Give patient clear, concise explanations of anything about to occur. Avoid information overload.

RATIONALE

EVALUATION Short Term:

Clear and concise information reduces the patients anxiety; an anxious patient cannot assimilate many details.

After 2 hours of nursing interventions the patient demonstrates activities that tend to reduce anxious behaviors such as: Performing a relaxation techniques (muscle relaxation) such as listening to music and bed rest comfortably. Expressing feeling to

Objective: Fidgeting Worry Fear

secondary to chronic kidney disease as manifested by: Fidgeting Worry Fear And patients verbalization of

Hospitalization

demonstrate activities that tend to reduce

Diagnosis of the condition (CKD)

anxious behaviors such as: Performing a Listen attentively; allow the patient to express feelings verbally. To build trust and reduces tension. This may also allow patient to identify anxious behaviors and discover source of anxiety

Lack of knowledge about the condition/first hospitalization

relaxation techniques (muscle relaxation) Expressing feeling to others (family, nurses

Fidgeting, worry, fear about her condition

and doctors) Make no demands on patient. Anxious patient may respond to excessive demands with hostility and abuse.

others (family, nurses and doctors).

Identify and reduce many environmental stressors as possible.

Anxiety commonly results from lack of trust in the environment.

Long Term: After 4-5 days of nursing interventions, the patient will cope with current medical condition without demonstrating anxiety.

Have patient state what kind of activities promote feeling of comfort, and encourage the patient to perform them.

These gives patient a sense of control.

Long Term: After 5 days of nursing interventions, the patient copes with current medical condition without demonstrating anxiety.

Include patient in decisions related to care when feasible.

Anxious patient may mistrust own abilities; involvement in decision-making may reduce anxiety behavior.

Support family members Involving family in coping with patients anxious behavior. members in process of reassurance and explanation allays patients anxiety as well as their own.

Teach patient a relaxation technique to be performed every 4 hours, such as guided imagery, progressive

These measures can restore psychological and physical equilibrium by decreasing autonomic

muscle relaxation and meditation.

response to anxiety.

Reference: Nursing Diagnosis reference manual 6th edition by Sparks and Taylor p. 37