Medical Diagnosis: Renal Failure

Problem: Fluid Volume Excess RT Decreased Glomerular Filtration Rate and Sodium Retention

Assessment Nursing Diagnosis Planning Interventions Evaluation

Subjective: Fluid Volume Short Term: 1. Establish rapport Short Term:
Confusion, Excess R/T After 4-8 hours of 2. Monitor and record vital signs The patient shall have
weakness, fatigue decrease nursing 3. Assess possible risk factors demonstrated behaviors
and Muscle Glomerular interventions, 4. Monitor and record vital signs. to monitor fluid status
cramps, pain, loss filtration Rate and patient will 5. Assess patient’s appetite and reduce recurrence
of tone sodium demonstrate 6. Note amount/rate of fluid intake of fluid excess
Retention behaviors to from all sources
monitor fluid status 7. Compare current weight gain
2. Risk for and reduce with admission or previous Long Term:
Objective: decreased recurrence of fluid stated weight The patient shall have
Patient cardiac output excess 8. Auscultate breath sounds manifested stabilized
manifested: 9. Record occurrence of dyspnea fluid volume AEB
• Edema 3. Risk for Infection 10. Note presence of edema. balance I & O, normal
• Hypertension Depression of Long Term: 11. Measure abdominal girth for VS, stable weight, and
• Weight gain immunologic After 3 days of changes. free from signs of
• Pulmonary defenses nursing 12. Evaluate mentation for edema.
congestion (secondary to intervention the confusion and personality
(SOB, DOB) uremia) patient will changes.
• Oliguria Invasive manifest stabilize 13. Observe skin mucous
• Distended procedures/devices fluid volume AEB membrane.
jugular vein (e.g., urinary balance I & O, 14. Change position of client timely.
• Changes in catheterization) normal VS, stable 15. Review lab data like BUN,
mental status Changes in dietary weight, and free Creatinine, Serum electrolyte.
intake/malnutrition from signs of 16. Restrict sodium and fluid intake
edema. if indicated
4. Altered nutrition 17. Record I&O accurately and
less than body 18. calculate fluid volume balance
requirements 19. Weigh client and
related to anorexia 20. Assess skin, face, dependent
nausea and areas for edema
vomiting 21. Encourage quiet, restful
atmosphere.
22. Promote overall health
measure.
Fluid volume excess r/t compromised regulatory mechanism (renal failure)

Assessment Nursing Planning Interventions Evaluation

Diagnosis
Subjective: Fluid volume Short Term: Independent Short Term:
excess r/t After 8 hrs of • Record accurate intake and After 8 hrs of nursing
Metallic taste, compromised nursing output intervention goal met as
anorexia, nausea, regulatory intervention the evidence by the patient
mouth ulceration. mechanism patient will display • Weight daily at same day, displayed appropriate
SOB, pleuritic pain (renal failure) appropriate urinary same scale, same time, and urinary output with
output with same clothing specific gravity, vital
specific gravity, signs with in normal
“objective: 2.Activity vital signs with in • Assess skin, face, dependent range and absence of
• generalize intolerance normal range and areas for edema edema
edema related to fatigue absence of edema
• patient and retention of • Plan oral fluid replacement with Long term goal after 4
reports of waste products Long term goal patient, within multiple days of nursing
fatigue, after 4 days of restrictions intervention goal met as
weakness, nursing evidence by the patient
and malaise intervention the displayed stable weight
• weight 53kg patient will display from 53kg to 51kg
vital sign taken stable weight from
as follows: 53kg to 51kg
• bp-
140/90mmHg
• pr-60bpm
• rr-20cpm
• T-36.7C