Nursing Care Plans Problems Physiologic overload: Edema Objective cues: - Oliguria ( <400 cc/ day of urine output prior to intake of medicatio ns) - Dry, poor skin turgor - Restless - Edematous foot, right, nonpitting Subjective cues: “na-worry lang ko day ba kay taggagmay na lang jud ang akung ihi unya nanghupong pud ku” Nursing diagnosis Fluid volume overload: Edema related to decreased urine output Scientific basis Acute renal failure is a sudden and almost complete loss of kidney function over a period of hours to days. ARF manifests oliguria, anuria, and normal urine output are not as common. Thus, when there is less waste product excreted such as urine into normal daily urine output, decreased urine output is the most common outcome followed by edema. Source: Medicalsurgical nursing, Brunner and Suddarth, p. 1321, vol 2, 8th edition Objectives of care After 3 days of holistic nursing care, the patient will be able to stabilize fluid volume as evidence by balance I/O Nursing interventions Measures to stabilize fluid volume: Rationale

1. weigh daily Provides a or on regular comparative schedule, as baseline indicated 2. limit fluid intake to prescribed volume Fluid restriction will be determined on basis of weight, urine output, and response to therapy Unrecognized sources of excess fluids may be identified Understanding promotes patient and family cooperation with fluid restriction Increasing patient comfort promotes compliance with dietary restrictions hygiene

3. identify potential sources of fluid 4. explain to patient and family rationale for fluid restriction 5. assist patient to cope with the discomforts resulting from fluid restriction 6.

provide Oral

frequent oral minimizes hygiene dryness of oral mucous membranes 7. administer To provide medications treatment of as ordered the disease Source: textbook of medicalsurgical nursing, Brunner and Suddarth,p. 1532, 11th ed.

Problems Physiologic deficit: Imbalanced nutrition Objective cues: - Pale conjunctiva -weakness of muscles due to food restriction - decreased appetite to eat -cracked lips due to inadequate food intake Subjective cues: “wala jud kuy gana mukaon day kay wala ku maanad s mga pagkaon nga ila ginapakaon naku. Dili ku ganahan”

Nursing Diagnosis Imbalanced nutrition: less than body requirements: decreased appetite related to dietary restrictions

Scientific Basis ARF causes nutritional imbalances, impaired glucose use and protein synthesis and increased tissue catabolism. Dietary restrictions are required in patient with ARF so as to maintain and minimize nutritional imbalances. Patient on this stage seems to have a hard time in adjusting his new set of diet and takes time to get used to eat the new set of foods serve. Proper supervision is then advised. Source: Brunner and Suddarth, textbook of medical surgical nursing, 11th ed., p. 1526

Objectives of Care After 8 hours of holistic nursing care, patient will be able to improve her appetite on the foods serve per dietary restrictions

Nursing Interventions Measures to improve appetite: 1. provide frequent oral hygiene


Frequent oral hygiene will keep oral mucous membranes moist and stimulate saliva production, which can help increase the patient’s oral intake Increased dietary intake is encouraged

2. provide patient’s food preference within dietary restrictions 3. promote intake of high biologic value protein foods: eggs, dairy products, meats 4. encourage high-calorie, low sodium, and lowpotassium snacks between meals 5. alter schedule of medications

Complete proteins are provided for positive nitrogen balance Reduces source of restricted food and proteins and provides calories for energy Ingestion of medication before meals

so that they are not given immediately before meals 6. explain rationale for dietary restrictions and relationship to kidney disease and increased urea and creatinine levels 7. provide written lists of foods allowed and suggestions for improving their taste without use of sodium or potassium

may produce anorexia and feeling of fullness Promotes patient understanding of relationships between diet and urea and creatinine levels to renal disease Lists provide a positive approach to dietary restrictions and a reference for patient and family to use when at home

Problems Physiologic deficit: Fatigue Objective cues: -weakness -decreased chances to perform ADLs (unfixed hair, unchanged clothes for 2days) -inability to walk without assistance Subjective cues: “nkafeel jd kug pgkaluya krun day”

Nursing diagnosis Activity intolerance: fatigue related to generalized weakness

Scientific basis Almost every system of the body is altered when there is failure of the normal renal regulatory mechanisms. The patient may appear clinically ill and lethargic. Patient with ARF usually exhibits signs of fatigue, the skin and mucous membranes may be dry due to dehydration. Source: Brunner and Suddarth, textbook of medicalsurgical nursing, 11th ed., p.1523

Objectives of care After 8 hours of holistic nursing care, patient will be able to verbalize decrease weakness as evidence by capability to perform simple task like combing hair

Nursing intervention Measures to decrease weakness: 1. provide a positive atmosphere, while acknowledging difficulty of the situation for the patient 2. promote independence in self-care activities 3. encourage alternating activity with rest


Helps to minimize frustrations, rechannel energy

Promotes improved self-esteem Promotes activity and exercise within limits and adequate rest To prevent overexertion To protect client from injury To prevent injuries

4. adjust activities 5. assist with activities 6. assist client to learn and demonstrate appropriate safety measures 7.encourage client to use positive attitude: suggest use of

To enhance sense of wellbeing

relaxation techniques, such as visualization/ guided imagery Source: Brunner and Suddarth, textbook of medical surgical nursing, 11th ed., p. 1534 & Marilynn Doenges, nurses pocket guide, 9th ed., p. 60-63

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