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XI.

NURSING CARE PLAN

Assessment
Subjective Minsanhindiniyatalagamapigilankumainngbawalsakany a. Yung pag-inomniyangtubig, hindiniyamabawasan. Urinates 4 times a day with little amount of urine Objective 10 cpm; clients breathing is normal when on side lying position. Distress (+) Edema Hemoglobin = 5.93 (below normal) Hematocrit = 17.98 (below normal) BP = 150/100

Nursing Diagnosis
Fluid Volume Excess R/T decrease Glomerular filtration Rate and sodium retention

Analysis
Renal disorder impairs glomerular filtration that resulted to fluid overload. With fluid volume excess, hydrostatic pressure is higher than the usual pushing excess fluids into the interstitial spaces.

Goals and Objectives Goal: After 2 weeks of nursing intervention the patient will maintain ideal body weight without excess fluid.

Interventions 1. Establish rapport

Rationale 1. To gain the trust of the patient 2. To have baseline data

Evaluation The patient maintained ideal body weight without excess fluid.

2. Monitor and record vital signs and invasive hemodynamic prarameters if available

3. Auscultate breath sounds


4. Measure abdominal girth for changes

3. For presence of crackles or congestion 4. that may indicate increasing fluid retention/edema 5. For confusion, personality changes. 6. To monitor any changes and what

5. Evaluate mentation

Goals and Objectives Objectives: After 1 week of nursing intervention s, the patient will promote elimination of excess fluid.

Interventions

Rationale

Evaluation The patient promoted elimination of excess fluid.

1. Record accurate intake 1.Accurate I&O is necessary and output. for determining renal function and fluid replacement needs and reducing risk of fluid overload 2. Weigh daily at same time of day, on same 2. Daily body weight is best scale, with same monitor of fluid status. equipment and clothing

3. Assess skin, face, dependent areas for edema

3.Edema occurs primarily in dependent tissues of the body, e.g., hands, feet, lumbosacral area. Patient can gain up to 10lb (4.5 kg) of fluid before pitting edema is detected 4. To reduce tissue pressure and rick of skin breakdown

4. Evaluate edematous ectremeties, change position frequently

Goals and Objectives Objectives: After 1 week of nursing intervention s, the patient will promote elimination of excess fluid.

Interventions

Rationale

Evaluation

5. Place in semi fowlers position as appropriate to facilitate movement of diaphragm improving respiratory effort 6. Administer medication as indicated a. Diuretics, e.g., furosemide (Lasix), mannitol (Osmitrol)

5. To facilitate movement of diaphragm improving respiratory effort

The patient promoted elimination of excess fluid.

6.a. Given early in oliguric phase of Renal Failure in an effort to convert to nonoliguric phase, flush the tubular lumen of debris, reduce hyperkalemia, and promote adequate urine volume. 6.b. May be given to treat hypertention by counteracting effects of decreased renal blood flow and/or circulating volume overload.

b.Antihypertensives, e.g., clonodine (Catapres)

Goals and Objectives 2. After 3 days of nursing intervention s, the patient will demonstrat e no rapid weight gain.

Interventions

Rationale

Evaluation

1. Assess the fluid status: a. Daily weight b. Intake and output balance c. Skin turgor and presence of edema d. Distention of neck vein e. blood pressure, pulse and rhythm f. respiratory rate and effort 2. Limit fluid intake to prescribed volume

1. Assessment provides baseline and ongoing database for monitoring changes and evaluating interventions.

The patient demonstrated no rapid weight gain

2. Fluid restriction will be determined on basis of weight, urine output, and response to therapy 3. Unrecognized sources of excess fluids may be identified

3. Identify potential source of fluid: a. Medications and fluids used to take medications; oral and intravenous

Goals and Objectives 3. After 1 day of nursing intervention s, the patient will maintain dietary and fluid restrictions.

Interventions

Rationale

Evaluation

1. Explain to the patient and the family rationale for restriction.

1. Understanding promotes patient and family cooperation with dietary and fluid restrictions. 2. Salty food can contribute to fluid retention.

The patient maintained dietary and fluid restrictions.

2. Tell the patient to avoid salty food.

3. Assist the family plan a meal

3. To help them identify the right food for the patient.