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(lanore Lhe Monkev)

Med|ca| D|agnos|s 8enal lallure
rob|em lluld volume Lxcess 81 uecreased Clomerular lllLraLlon 8aLe and Sodlum 8eLenLlon
Assessment Nurs|ng D|agnos|s 5c|ent|f|c
Lxp|anat|on
|ann|ng Intervent|ons kat|ona|e Lva|uat|on
5ub[ect|ve (none)

Cb[ect|ve
at|ent man|fested
O Ldema
O vperLenslon
O JelahL aaln
O ulmonarv
conaesLlon (SC8
uC8)
O Cllaurla
O ulsLended [uaular
veln
O Chanaes ln
menLal sLaLus
at|ent may
man|fest

lluld volume Lxcess
8/1 decrease
Clomerular fllLraLlon
8aLe and sodlum
reLenLlon
8enal dlsorder
lmpalrs alomerular
fllLraLlon LhaL
resulLed Lo fluld
overload JlLh fluld
volume excess
hvdrosLaLlc pressure
ls hlaher Lhan Lhe
usual pushlna excess
flulds lnLo Lhe
lnLersLlLlal spaces
Slnce flulds are noL
reabsorbed aL Lhe
venous end fluld
volume overloads Lhe
lvmph svsLem and
sLavs ln Lhe
lnLersLlLlal spaces
leadlna Lhe paLlenL Lo
have edema welahL
aaln pulmonarv
conaesLlon and n
aL Lhe same Llme due
Lo decrease Cl8
nephron
hvperLhrophlzed
leadlna Lo decrease
ablllLv of Lhe kldnev
Lo concenLraLe urlne
and lmpalred
excreLlon of fluld
Lhus leadlna Lo
5hort 1erm
AfLer 48 hours of
nurslna
lnLervenLlons paLlenL
wlll demonsLraLe
behavlors Lo monlLor
fluld sLaLus and
reduce recurrence of
fluld excess


Long 1erm
AfLer 3 davs of
nurslna lnLervenLlon
Lhe paLlenL wlll
manlfesL sLablllze
fluld volume AL8
balance l C normal
vS sLable welahL
and free from slans
of edema
1 LsLabllsh rapporL



2 MonlLor and
record vlLal slans

3 Assess posslble
rlsk facLors


4 MonlLor and
record vlLal slans


3 Assess paLlenL's
appeLlLe




6 noLe
amounL/raLe of
fluld lnLake from
all sources


7 Compare currenL
welahL aaln wlLh
admlsslon or
prevlous sLaLed
welahL
1 1o assess
preclplLaLlna and
causaLlve facLors

2 1o obLaln
basellne daLa

3 1o obLaln
basellne daLa


4 1o noLe for
presence of
nausea and
vomlLlna

3 1o prevenL fluld
overload and
monlLor lnLake
and ouLpuL

6 1o monlLor fluld
reLenLlon and
evaluaLe dearee
of excess


7 lor presence of
crakles or
conaesLlon


5hort 1erm
1he paLlenL shall
have demonsLraLed
behavlors Lo monlLor
fluld sLaLus and
reduce recurrence of
fluld excess


Long 1erm
1he paLlenL shall
have manlfesLed
sLablllzed fluld
volume AL8 balance l
C normal vS
sLable welahL and
free from slans of
edema
1hls nC was made wlLh love bv NursesLabscom
(lanore Lhe Monkev)
ollaurla/anurla

8 AusculLaLe
breaLh sounds

9 8ecord
occurrence of
dvspnea

10 noLe presence of
edema

11 Measure
abdomlnal alrLh
for chanaes

12 LvaluaLe
menLaLlon for
confuslon and
personallLv
chanaes

13 Cbserve skln
mucous
membrane

14 Chanae poslLlon
of cllenL Llmelv


13 8evlew lab daLa
llke 8un
CreaLlnlne
Serum
elecLrolvLe

16 8esLrlcL sodlum
and fluld lnLake lf
lndlcaLed
8 1o evaluaLe
dearee of excess

9 1o deLermlne
fluld reLenLlon

10 Mav lndlcaLe
lncrease ln fluld
reLenLlon

11 Mav lndlcaLe
cerebral edema


12 1o evaluaLe
dearee of fluld
excess



13 1o prevenL
pressure ulcers

14 1o monlLor fluld
and elecLrolvLe
lmbalances

13 1o lessen fluld
reLenLlon and
overload




16 1o monlLor
kldnev funcLlon
and fluld
1hls nC was made wlLh love bv NursesLabscom
(lanore Lhe Monkev)

17 8ecord lC
accuraLelv and
calculaLe fluld
volume balance

18 Jelah cllenL


19 Lncouraae quleL
resLful
aLmosphere

20 romoLe overall
healLh measure

reLenLlon
17 JelahL aaln
lndlcaLes fluld
reLenLlon or
edema

18 JelahL aaln mav
lndlcaLe fluld
reLenLlon and
edema
19 1o conserve
enerav and lower
Llssue oxvaen
demand
20 1o promoLe
wellness