Independent SUBJECTIVE: Fluid Volume Renal failure After 8 hours of Goal met, “Namamanas excess r/t nursing • Record accurate • Accurate I&O is patient has ako at ang hina Compromised intervention, the intake and output necessary for displayed ng katawan ko” regulatory Decrease blood patient will (I&O). determining renal appropriate (I have edema and mechanism flow to kidneys display function and fluid urinary output I feel very weak) (renal failure) appropriate replacement needs with specific as verbalized by urinary output and reducing risk of gravity/laborato the patient Decrease with specific fluid overload ry studies near perfusion in gravity/laborator normal; stable kidney y studies near • Weigh daily at • Daily body weight, vital OBJECTIVE: normal; stable same time of day, on weight is best signs within weight, vital same scale, with monitor of fluid patient’s • Venous Decrease signs within same equipment and status normal range; distension urinary output patient’s normal clothing and absence of • Generaliz range; and edema. ed edema absence of • Assess skin, • Patient Water retention edema. face, dependent • Edema occurs reports of areas for edema primarily in Fatigue, dependent tissues weakness, Fluid volumes of the body, e.g., and malaise excess hands, feet, • V/S taken lumbosacral area. as follows Patient can gain up to 10 lb (4.5 kg) of T: 35˚C fluid before pitting P: 50 edema is detected R: 13 • Plan oral fluid BP: 130/90 replacement with • Helps avoid patient, within periods without multiple restrictions fluids, minimizes boredom of limited choices, and reduces sense of Kong, Michael Robert NCP
Collaborative deprivation and
thirst • Administer/restric t fluids as indicated. • Fluid management is usually calculated to replace output from all sources plus • Administer estimated insensible medication as losses indicated Diuretics, e.g., • Given early in furosemide (Lasix), oliguric phase of mannitol (Osmitrol) Renal Failure in an effort to convert to nonoliguric phase, flush the tubular lumen of debris, reduce hyperkalemia, and • Antihypertensive promote adequate s, e.g., clonidine urine volume. (Catapres) • May be given to treat hypertension by counteracting effects of decreased renal blood flow and/or circulating volume overload