NURSING DIAGNOSIS
Fluid volume excess related to
compromised regulatory
mechanism secondary to acute
kidney injury as evidenced by:
“Nag mamanas ang dalawang paa
ko”.
 (+) Pitting edema 2+
 w/ ongoing HD 3x a week
 creatinine – 542
mmgm/L
 oliguria (>30ml urine
output/hr)
 (+) 5% weightgain for the
past 2 weeks
NURSING OBJECTIVES NURSING INTERVENTION
After 2 days of nursing
intervention, the patient will
manifest reduction in body fluid
as evidenced by:
 (+) Pitting Edema 1+
 HD scheduled will be
change to 2x a week
 Post HD weight will be
lesser than pre HD
weight.
EVALUATION
 Assessed for presence of GOALS MET
fluid volume excess in
other areas such as After 2 days of nursing
ascites facial edema intervention, pt RM manifested
 Reviewed lab results like reduction of body fluid as
BUN, Crea and serum evidenced by:
electrolytes
 Monitored v/s q4hrs and  (+) Pitting Edema 1+
recorded
 Monitored weight and  HD scheduled is changed
abdominal girth every to 2x a week
morning and every
dialysis  Post HD weight is lesser
 Advised to limit oral fluid than pre HD weight.
intake to 1-1.5L/day
 Note amount of fluid
intake from all sources
 Changed position of
client timely.
 Advised low salt low fat
diet
 Taught range of motion
exercises as tolerated
 Encouraged to attend
religiously HD sessions