Nursing Diagnosis
Independent:
Fluid Volume Excess related to
compromised regulatory
mechanism (renal failure) as
evidenced by elevated creatinine
level
Subjective Data:
“nag dyutay na akon pangihi”
Objective Data:
- Swelling of both lower
extremities
- Urine output of less than
200ml in 8 hours
- Creatinine level of 14mmol
- Decreased hgb level
(101g/L)
Goal Plan:
After 8 hours of nursing
intervention the patient will
display appropriate urinary
output
Rationale Intervention
1. Record accurate intake and
Renal Failure output.
 replacement needs and
decrease blood flow to kidneys
 output.
decrease perfusion in kidneys
 2. Assess skin, face, and
decrease urinary output dependent areas for edema

water retention

3. Assess for crackles in the lungs,
fluid volume excess changes in respiratory pattern,
shortness of breath and
orthopnea.
4. Plan oral fluid replacement
with multiple restrictions.
Dependent:
1. Administer or restrict fluid as
Rationale Intervention
1. It is necessary to determine
renal function and fluid After 8 hours of nursing
intervention the patient will
monitoring risk of fluid overload. display a balanced intake and
2. Edema occurs primarily in
dependent tissues of the body.
(hands, feet, lumbosacral area)
3. These signs are caused by an
accumulation of fluid in the lungs.
Helps avoid periods without
fluids, minimizes boredom of
limited choices and reduces sense
of deprivation and thirst.
1. Fluid management is usually
calculated to replace output from
all sources plus estimated
 indicated. insensible losses.

2. aids in the excretion of excess

2. Administer medication as
indicated.
(Diuretics –Furosemide)
Antihypertensives (Amlodipine)
body fluids.
May be given to treat
hypertension by counteracting
effects of decreased renal blood
flow and or circulating volume
overload.

Nursing Diagnosis Rationale Intervention Rationale

Intervention

Impaired skin integrity related to
impaired circulation as evidenced
by edematous lower extremities.
Subjective Data:
“Gahubag ang akon duwa ka tiil”
Objective Data:
1. Assess the overall
condition of the skin.
2. Evaluate the patient’s
awareness of the sensation
of pressure.
3. Assess patient’s nutritional
status, including weight,
weight loss, and serum
albumin levels.
A healthy skin should have
good turgor (an indication of
moisture), feel warm and dry
to the touch, be free from
impairment (cuts, wounds,
abrasions, excoriation,
outbreaks, and rashes), and
have quick capillary refill
(less than 6 seconds). 
Patients who are unaware of
sensation tend to do nothing
thus results in prolonged
pressure on skin capillaries
and eventually in skin
ischemia.
An albumin level less than
2.5 g/dL is a grave sign,
indicating severe protein
depletion and at high-risk of
skin breakdown.