ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
Defining Characteristics
Subjective:  Fluid Volume Excess related to
“naga habok akon tiil kag
nabudlayan ako mangihi” as
verbalized by the patient.
Objective:
● 2+ pedal edema
● basilar crackles in the
lungs bilaterally
● a scant amount of urine
according to a bladder
scan.
● body weakness
Vital signs
● BP: 170/90 mmHg
● Respiratory rate: 28 cycles
per minute.
ECG = sinus tachycardia
CXR= Bilateral Pneumonia with
minimal Pleural Effusion.
Laboratory;
Serum urea of 94.13 mmol/L
Creatinine 3202 umol/L
Uric acid 30.5 mg/dl
West Avenue, Molo, Iloilo City
NURSING CARE PLAN
Nursing Diagnosis Outcome Nursing Intervention Rationale Evaluation
Identification
Long Term: Independent: The goal is partially met
impaired excretory function as After 10 days of Establish rapport To get the cooperation as the patient can urinate
evidenced by 2+ pedal edema, a nursing intervention, of the patient frequently in small
scant amount of urine, BP 170/90 the patient will have amounts and have
mmHg. stabilized fluid volume Assess fluid status: The assessment stabilized fluid volume as
as evidenced by -Daily weight provides a baseline evidenced by a balance in
balanced I & O, and -Intake and output and ongoing database I & O, normal VS BP
Rationale: free from signs of balance for monitoring 120/80 mmHg, RR= 18
Renal failure impairs glomerular edema. -Skin turgor and changes and bpm, and no signs of
filtration that can result in fluid presence of edema evaluating edema.
overload. With fluid volume excess, -Vital signs interventions.
hydrostatic pressure is higher than Short Term:
usual pushing excess fluids into the After 2 days of Note for the presence To determine fluid
interstitial spaces. Since fluids are nursing intervention, of edema. retention.
not reabsorbed at the venous end, the patient will have a
fluid volume overloads the lymph normal urine Record I&O To monitor kidney
system and stays in the interstitial elimination and accurately and function and fluid
spaces leading the patient to have normal VS. calculate fluid volume retention.
edema, weight gain, pulmonary balance
congestion, and HPN at the same
time due to decreased GFR, nephron Note amount/rate of To prevent fluid
hypertrophied leading to decreased fluid intake from all overload.
ability of the kidney to concentrate sources.
urine and impaired excretion of fluid
thus leading to oliguria/anuria. Review for a To assess for
laboratory test for contributing or
Reference: https://nurseslabs.com changes in renal causative factors.
function.
Palpate bladder To assess retention
Determine  usual daily To help determine the
fluid intake level of hydration.
Note the condition of To assess the level of
the skin and mucous hydration.
membranes, the color
of urine.

Elevate edematous Elevation increases

extremities, and venous return to the
handle with care. heart and, in turn,
decreases edema.
Edematous skin is
more susceptible to
injury.

Place the patient in a Raising the head of the

semi-Fowler’s or high- bed provides comfort
Fowler’s position. in breathing.

Aid with repositioning

every 2 hours if the Repositioning prevents
patient is not mobile. fluid accumulation in
dependent areas.

Dependent:
Administer medication
as prescribed.

Furosemide +
Potassium (Diumide- A potent loop diuretic
K) that inhibits sodium
OD p.c. and chloride
8 reabsorption at the
proximal and distal
tubules and the
ascending loop of
Ketoanalogue 2 tablets Henle
PO TID
8-1-6 Used with very low
protein diets to prevent
protein deficiencies.
 Ketoanalogues (KAs)
are effective in
improving the benefits
of a low-protein diet
for patients with
chronic kidney disease
(CKD).
PNSS 1L x KVO.  
To replace the loss of
fluid volume, to treat
dehydration and as a
route of IV
medications.

Low salt diet as

prescribed. To lessen fluid
retention and overload.

Hemodialysis
nursing management Hemodialysis is a
-check the patients' procedure where a
vital signs and talk dialysis machine and a
with them to assess special filter called an
their condition. artificial kidney, or a
-teach patients about dialyzer, are used to
their disease and its clean your blood.
treatment and answer
any questions.
-oversee the dialysis
treatment from start to
finish making sure
patients are given the
correct medications
ordered by their
doctors.
-evaluate patients'
reaction to the dialysis
treatment and
medications.
-review the patients'
lab work, home
medications and
activities and letting
the doctors know
about changes in their
patients' conditions.
-helping patients
follow-up with their
transplant center
supporting the entire
care team in delivering
quality care in a
considerate, respectful
manner.

Medications:

Erythropoietin 4000 u’
SC OD twice a week Erythropoietin
8 regulates
erythropoiesis by
stimulating the
differentiation and
proliferation of
erythroid precursors,
stimulating the release
of reticulocytes into
the circulation, and
synthesis of cellular
Ferrous sulfate + folic haemoglobin.
acid 1 tablet TID
8-1-6 Stimulates normal
erythropoiesis and
nucleoprotein
Amlodipine 40 mg/1 synthesis.
tab OD
8 Inhibits calcium ion
influx across cardiac
and smooth muscles,
 thus decreasing
myocardial
contractility and
oxygen demand; also
dilates coronary
Clonidine 75mcg/tab arteries and arterioles.
SL prn for (BP>
160/90) Thought to stimulate
alpha adrenergic
receptors centrally and
inhibit the central
vasomotor centers,
thereby decreasing
sympathetic outflow to
the heart, kidneys, and
peripheral vasculature,
resulting in decreased
peripheral vascular
resistance, systolic and
diastolic blood
pressure, and heart
Furosemide 20mg rate.
IVTT Q12H
8-8 A potent loop diuretic
that inhibits sodium
and chloride
reabsorption at the
proximal and distal
tubules and the
ascending loop of
Henle.
Insulin Ryzodeg 15
units SC OD Insulin degludec and
insulin aspart binds
specifically to the
human insulin receptor
and results in the same
pharmacological
effects as human
insulin.
 Clopidogrel 75mg 1
tab OD Clopidogrel is an
1 inhibitor of platelet
aggregation.
Carvedilol 6.25mg 1
tab OD Non-selective beta-
8 blocker with alpha 1-
blocking activity.

Piperacillin + Piperacillin kills

Tazobactam 2.25gm bacteria that cause
IV q8h ANST(-) infection while
8-4-12 Tazobactam prevents
bacteria from
destroying piperacillin

Defining Characteristics Nursing Diagnosis Outcome Nursing Interventions Rationale Evaluation

Identification
Subjective: Altered Renal Tissue Perfusion Long Term: Independent: After nursing
related to glomerular malfunction After 7 days of Establish rapport To get the interventions, goals
secondary to chronic renal failure nursing interventions, cooperation of the are met as evidenced
the patient will patient by no signs of pedal
demonstrate reduced edema, clear breath
extracellular fluid sounds, normal blood
volume by weight Assess and monitor vital To establish baseline pressure level,
Objective: Rationale: loss, decreased pedal signs. data. To monitor the respiratory rate, and
● 2+ pedal edema For optimal cell functioning the edema, and clear lung patient’s blood normal urine output.
● basilar crackles in the kidney excrete potentially harmful sounds and have pressure levels as
 lungs bilaterally
● a scant amount of urine
according to a bladder
scan.
● body weakness
● difficulty of urinating.
Vital signs
● BP: 170/90 mmHg
● Respiratory rate: 28
cycles per minute.
ECG = sinus tachycardia
CXR = Bilateral Pneumonia with
minimal Pleural Effusion.
Laboratory;
Serum urea of 94.13 mmol/L
Creatinine 3202 umol/L
Glomerular filtration rate (GFR)
of 6
Uric acid 30.5 mg/dl
nitrogenous product-Urea, normal urine output. hypertension can
Creatinine, Uric Acid but because of worsen kidney
the loss of kidney excretory damage. Fever can
functions, there is impaired indicate disease
excretion of the nitrogenous waste progression or the
product causing an increase in presence of infection.
Laboratory result of BUN,
Creatinine, Uric Acid Level. To monitor renal
function.
Short Term:
After 5 hours of Monitor the necessary To reduce the stress
Reference:https://nurseslabs.com. nursing intervention, blood tests as ordered. on the kidneys.
the patient's vital signs
will be on normal Monitor blood glucose To assess the fluid
limits. levels especially if the volume status of the
patient is diabetic. patient. To check for
signs of worsening
Weigh the patient daily. renal function and
Commence strict input and perfusion.
output monitoring. Note the
characteristics of the urine. For lung expansion to
promote comfort in
breathing.
Place the patient in semi-
fowler's or high- fowler's
position
Dependent:
Administer medication as
prescribed:
PNSS 1L x KVO. To replace the loss of
fluid volume, to treat
dehydration and a
 route for IV
medication.

Amlodipine (Norvasc) 40 An antihypertensive

mg/1 tab OD that inhibits calcium
8 ion influx across
cardiac and smooth
muscles, thus
decreasing
myocardial
contractility and
oxygen demand; also
dilates coronary
arteries and
arterioles.

Clonidine (Catapres) Antihypertensive

75mcg/tab Sublingual stimulates alpha-
PRN for (BP> 160/90) adrenergic receptors
centrally and inhibits
the central vasomotor
centers, thereby
decreasing
sympathetic outflow
to the heart, kidneys,
and peripheral
vasculature, resulting
in decreased
peripheral vascular
resistance, systolic
and diastolic blood
pressure, and heart
rate.

Carvedilol is used
Carvedilol alone or together
6.25mg 1 tab PO with other medicines
OD to treat high blood
8 pressure.

Furosemide + Potassium
Oral OD p.c.
8 and water. It does
Ketoanalogue 2 tablets PO
TID
8-1-6
Hemodialysis
nursing management
-check the patients' vital
signs and talk with them to
assess their condition.
-teach patients about their
disease and its treatment
and answer any questions.
-oversee the dialysis
treatment from start to
finish making sure patients
are given the correct
Furosemide works by
helping your body
get rid of excess salt
this by increasing the
amount of urine your
body makes. This
helps lower your
blood pressure as
well as reduce
swelling.
Used with very low
protein diets to
prevent protein
deficiencies.
Ketoanalogues (KAs)
are effective in
improving the
benefits of a low-
protein diet for
patients with chronic
kidney disease
(CKD).
Hemodialysis is a
procedure where a
dialysis machine and
a special filter called
an artificial kidney,
or a dialyzer, are
used to clean your
blood.
medications ordered by
their doctors.
-evaluate patients' reaction
to the dialysis treatment
and medications.
-review the patients' lab
work, home medications
and activities and letting
the doctors know about
changes in their patients'
conditions.
-helping patients follow-up
with their transplant center
supporting the entire care
team in delivering quality
care in a considerate,
respectful manner.

Medications:
Erythropoietin 4000 u’ SC Erythropoietin
OD twice a week regulates
8 erythropoiesis by
stimulating the
differentiation and
proliferation of
erythroid precursors,
stimulating the
release of
reticulocytes into the
circulation, and
synthesis of cellular
haemoglobin.

Ferrous sulfate + folic acid Stimulates normal

1 tablet TID erythropoiesis and
8-1-6 nucleoprotein
synthesis.

Furosemide 20mg IVTT A potent loop

Q12H diuretic that inhibits
 8-8 sodium and chloride
reabsorption at the
proximal and distal
tubules and the
ascending loop of
Henle.

Insulin Ryzodeg 15 units Insulin degludec and

SC OD insulin aspart binds
specifically to the
human insulin
receptor and results
in the same
pharmacological
effects as human
insulin.

Clopidogrel 75mg 1 tab OD Clopidogrel is an

1 inhibitor of platelet
aggregation.

Piperacillin + Tazobactam Piperacillin kills

2.25gm IV q8h ANST(-) bacteria that cause
8-4-12 infection while
Tazobactam prevents
bacteria from
destroying
piperacillin