NCP Excess fluid volume r/t stasis of fluid in the body Cues Nursing diagnosis Scientific explanation Planning

Interventions Rationale Expected outcome

S> O: the

Excess

fluid Acute

kidney Short term: formerly 4hrs of

 Establish rapport and assess general condition.

 To trust

gain Short term: and the patient shall have demonstrated behaviours to fluid and

volume r/t stasis injury

patient of fluid in the known as acute After the body renal failure is nursing

establish baseline data

manifest following:

the abrupt loss intervention the of kidney pt. demonstrate to behaviours falls monitor of the status reduce of to fluid and will  Note presence of

 Edema upper

on

function resulting sudden down

monitor assess status

medical  To or that

extremities, face neck  Oliguria  Hematuria  Rales  Hgb: 78 and

conditions situations

causative or reduced precipitating recurrence factors fluid excess. of

glomerular

potentiate fluid excess.

volume

filtration rate. A recurrence damage which may cause of fluid excess.

volume  Auscultate breath sounds  To note Long term:

 Hct: 0.25  Ph: 6.6  SG: 1.025  BP: 160/80

failure

of

the

presence of fluid congestion to The shall stabilized patient have fluid as by I/O, within limits, weight free of

kidneys to filter Long term: large molecules. including with molecule those After 3-4 days of  Advice larger nursing can intervention the

restrict sodium  To prevent volume and fluid intake, as indicated. more evidence retention of balanced fluids VS normal I/O . stable

The patient may manifest the following:  Jugular vein distention  Positive hepatojugula r reflex

pass through the patient will have GFR leading proteinuria, thus stabilize to volume evidence fluid as

by  Record accurately.

There is excess balance in intake fluid because of volume and output, VS of within protein stable pts limits, weight

 To know the and gains losses body. of

and signs of edema.

decreased levels normal

fluids in the

specifically albumin regulates oncotic pressure. With

and free of signs  Assess which of edema. neuromuscular reflexes  To evaluate for presence of electrolyte  Weigh daily or imbalances

low levels, fluid

is retained and not excreted.

on

regular as  To note the changes in weight.

schedule, indicated.

 Stress need for mobility frequent position changes and  To prevent stasis and reduce risk of injury .  Suggest interventions, such frequent care, gum/hard candy, use of lip balm as oral  To of reduce discomfort fluid tissue

chewing

restrictions

 Administer medications

 To decrease level of fluid volume excess

Ineffective renal tissue perfusion r/t impaired renal function Cues Nursing diagnosis Scientific explanation Planning Interventions Rationale Expected outcome

S>O

Ineffective renal One of the risk Short term: tissue perfusion factor of patient

 Establish rapport and assess general condition  Determine factors to related individual

 To gain trust Short term: and establish baseline data the patient shall have demonstrated  To assess behaviours/ or lifestyle changes improve circulation. to causative contributing factors

O:the manifest following:  Edema upper

patient r/t

impaired having

acute After 4r of NI, the will

the renal function

kidney injury is patient diabetes demonstrate mellitus. Wherein behaviours/

on

the patient has lifestyle type 2 diabetes to

changes improve

extremities, face and neck  Oliguria  Hematuria  Hct: 0.25  Ph: 6.6  SG: 1.025  Albumin 3+

mellitus it occurs circulation. when pancreas produces insufficient amounts of the hormone insulin and/or the bodys tissues become the

situation

 Note customary  To baseline data with

provide

comparison current

findings.

 Determine usual  To

know

resistant

to

voiding pattern

presence oliguria polyuria

of or

normal or even high insulin. causes blood The patient may manifest: (sugar) levels of Long term: This high After 3-4 days of  Review glucose NI, the patient will levels demonstrate as  Note mentation laboratory studies

Long term:  To there know if the patient shall are have demonstrated increased perfusion  To know if individually an appropriate. as

abnormalities in the results

leading to blood increased viscosity causing perfusion

 Urinary frequency hesitancy  anuria

decrease or

renal individually

blood flow which appropriate. may of result the to

theres alteration

impaired function kidneys causing improper tissue perfusion. There and which causes is circulation also a  Assess

brought about by increased or creatinine deacrease renal perfussion

impaired filtration

BP,  To determine

problem other systems processes

with body and like

ascertain patients range usual

degree renal impairment

of

oxygen transport in the blood and the like.

 Observe dependent generalized edema

for  To or

evaluate

severity of the disease condition.

 Administer medications as ordered

 To condition

treat

underlying

Impaired urinary elimination r/t glumerular malfiltration Cues Nursing diagnosis Scientific explanation Planning Interventions Rationale Expected outcome

S>

Impaired urinary

There exceed

is Short term: fluid After 4 hours of of nursing intervention the patient will be of able to verbalize understanding of the condition.

 Established rapport

 To gain trust and cooperation of the patient and significant others

Short term: the patient shall have verbalize understanding of the condition

O:

the

patient elimination r/t volume the glumerular malfiltration because decreased levels

manifest following:

 Edema on upper extremities, face and neck  Oliguria  Hematuria  Hct: 0.25  Ph: 6.6  SG: 1.025  Albumin 3+

protein specifically albumin which regulates oncotic

 Monitor and record Vital  To obtain baseline data signs

Long Term: the shall patient have

Long term:

participated in measures correct/ to

pressure. With After 3-4 days of  Assess low levels, fluid nursing intervention is retained and the patient will be not excreted. able to participate measures to patients general condition  To know what problem and

compensate for defects.

Loss of kidney in

functions as

and correct/compensate GFR for defects.  Review for lab test changes in renal function

interventions to prioritize

decreases, the kidney cannot excrete The patient may nitrogenous product causing  Urinary frequency/hesita ncy  anuria impairment the in and

 To assess for causative and contributing

manifest:

 Establish realistic activity/goal with the patient urinary

factors

 Enhance commitment s to promoting optimal

elimination and together prolonged usage medications can lead to of with

 Determine patients pattern of elimination

outcomes

further kidney destruction which further decrease the may

 To assess degree of interference

 Determine patient usual  To help

GFR destroys remaining

and the

fluid intake

determine level of

 Note condition of skin and mucous membranes and color of urine to

hydration

nephrons. This will result

 To assess level of hydration

inability of the kidney concentrate urine makes which the to

patient to have a diagnosis of impaired urinary elimination

 Emphasize the need to adhere with the prescribed diet  To prevent aggravation of disease condition

 Emphasize importance of having good hygiene

 To prevent spread of infection

 Emphasize importance of adhering to treatment regimen

 To promote wellness

Impaired skin integrity r/t facial edema and changes in skin pigmentation Cues Nursing diagnosis S>O impaired O:The manifests following:  Rough dry skin  Pruritus upper lower extremities and abdomen  Edema the neck upper on face, and on on and patient integrity the facial skin Because of the Short term: r/t complication edema the of  Establish rapport  To gain trust and cooperation the patient shall have identified  Establish baseline data individual risk Scientific explanation Planning interventions Rationale Expected outcome Short term:

underlying After 4r of NI, the patient will  Assess general risk condition

and changes in disease skin and pigmentation

condition which identify may result with individual the impairment factors that may

factors that may contribute to the disease

of the function of contribute to the  Assess the kidneys thus disease leading condition, to condition. the  Note presence edema With this condition

skin  To

reveal condition

abnormality/ skin disruption  To of causative/ Contributing factors. know Long term: the patient shall have demonstrated behaviours/

skin is stretched Long term: abnormally because of fluid After 2-3 days of retention. If the NI, the patient fluid will not be will demonstrate

conditions/ situations that may impair

skin integrity.

extremities

excreted,

there behaviours/ to  Monitor skin weight daily as indicated  To presence edema.

Techniques monitor prevent of breakdown.

to skin

is a possibility of Techniques impairment skin integrity. in prevent breakdown.

 Provide The patient may manifest:  Pain  Numbness on the affected  Impaired circulation  Impaired pigmentation  Emphasize importance of adequate nutrition area  Frequently change patients position meticulous skin care

 To prevent skin breakdown

 To and

promote

proper circulation prevent

excessive pressure on the skin

 To general

maintain good

health and skin turgor.

 Encourage exercise

 To

enhance

circulation

 Suggest use  To of lotions

decrease

irritable itching

 Administer diuretics ordered as

 To edema

decrease

Risk for injury r/t abnormal blood profile secondary to disease condition Cues Nursing diagnosis Scientific explanation Planning interventions Rationale Expected outcome

S=O O: The patient manifested

Risk injury abnormal

for The damage or SHORT TERM: r/t inflammation due After 3 hours of to the nursing of intervention the will

 Monitor signs

vital  To for

provide

baseline comparison

data

SHORT TERM:

future The pts shall have verbalized understanding of

blood profile complication disease condition. condition

 decreased in secondary to the haemoglobin  pale palpebral conjunctiva  pale beds  hgb count of 78 nail

disease patient which verbalize

 assess or fatigue

factors  To of

provide individual

factors

compresses renal understanding artery therefore of individual that to of

signs

appropriate interventions

that contribute to possibility of injury.

decreasing blood factors supply kidney suppresses to the contribute which possibility or injury.

 May  Note reports of increasing fatigue weakness or effects anemia cardiac

reflect of LONG TERM: and The patient shall

alters its function, one of the TERM: kidneys function LONG

have demonstrated behaviors, lifestyle changes to reduce

responses.

the patient may

is

to

produce After 2-3 days of

 Elevate

 To

maintain

risk

factors

and

manifest:  physical injury  bruises  sensory dysfunction

erythropoetin which responsible the carrying

nursing is interventions, for the patient will

HOB/position client appropriately

airway

protect injury

self

from and in

improvement  Promotes optimal chest in expantion laboratory values.

oxygen demonstrate behaviors,  Encourage frequent to risk and change position

component of the lifestyle blood, function decreases an changes factors

alteration in this reduce

and

deep-breathing  To rest limit to clients  To safety loss prevent demand oxygen limit a of

protect self from and  Provide adequate and activities within tolerance

oxygen supply to injury

the body causing improvement in anemia, causes which laboratory fatigue values.

consumption

and making the patient at risk for injury.

 Promote measure

injury and blood

 Provide oxygen

 To oxygen

increase supply

supplement as prescribed

in the body

 To  Administer meds as prescribed underlying conditions

treat

that

may aggravate the condition.

Ineffective Airway clearance related to retained secretions in the trachea-bronchial tree AEB rales upon auscultation Nursing diagnosis Scientific explanation Expected outcome

Cues

planning

interventions

rationale

S>O O :pt manifest the following  rales  changes in rate, depth of

Ineffective Airway clearance related to retained secretions in the tracheabronchial

The patient develop pulmonary congestion due to retention of fluid in the body, in diabetes mellitus fluid retention happen because with the abscence of glucose, the body will then metabolize protein in replacement of glucose that cant be metabolize for

Short Term: After 4 hours of nurse-patient interaction, the patients will demonstrate ways in improving airway patency.

 Monitor

and  To obtain baseline data  Tachypnea, of asymmetric movement because discomfort moving

record vital signs  Assess rate/depth respirations and chest movement. Monitor for signs of failure cyanosis severe tachypnea) respiratory (e.g. and

Short Term: The patient shall have

shallow resp., and demonstrated chest ways in are improving of of chest

frequently present airway patency

respirations tree AEB  pale palpebral conjuntiva  pale lips  nasal secretions  productive rales upon auscultation

and/or fluid in lung. Long Term: The patient

Long Term: After 1 week of  Auscultate lung

 Decreased airflow shall have

cough

energy production leading to protein wasting resulting to decrease colloid-oncotic pulling force in the intravascular

NPI, pt will maintain airway patency.

fields, areas

noting of

occurs

in

areas maintained with airway patency

consolidated fluid.

decreased/absen t airflow and

adventitious breath (e.g. sounds crakles,

the pt. may manifests:  rapid and shallow breathing  cyanosis  DOB  SOB  retractions

spaces. Thus, more fluid stays in the third space resulting to edema. This edema may occur at any part of the body like the lungs. This may lead to pulmonary congestion. The body is unable to clear the airway due to secretions.

wheezes)  Elevate head of  keeping bed, position frequently change elevated diaphragm, promoting expansion, aeration segments, mobilization expectoration of lung and and of chest head lowers

secretions to keep airway clear.

This fluid in the lungs may affect the oxygen and carbon dioxide diffusion in the alveoli. The function of the alveolar-capillary membrane becomes altered resulting to an impairment in the exchange of gases, which are oxygen and carbon dioxide

 Assist client with  Deep frequent breathing exercises. Demonstrate chest effective coughing while in upright position and deepfacilitates maximum

breathing

expansion lungs/smaller airways.

of

 Suction indicated

if  stimulates cough or mechanically clears airways

 Assist with/monitor effects nebulizer treatments and of

 facilitates liquefaction removal secretions and of

other respiratory

physio-therapy. Perform treatments between meals

and limit fluids when appropriate

 Administer medications indicated as

 Aids reduction

in

the of

bronchospasm and mobilization secretions. of