Assessment General Objectives: With NGT hooked at the left nostril With Mechani cal Ventilato r With Cardiac

iac Monitor With heplock at the right metacar pal vein With AVF at left arm With pulse Oxymete r (+) Venous Distentio n (+) Edema on the Left Upper Extremit y (+) muscle weaknes s with muscle

Diagnosis A1: Fluid Volume excess related to Compromise d regulatory mechanism secondary to renal failure

Planning P1: After the 8 hour of nursing intervention, the patient will display appropriate urinary output with specific gravity/laborato ry studies near normal; stable weight, vital signs within the patients normal range and absence of edema

Intervention Initiate NPI V/S monitored q4 and recorded especially RR and PR Record accurate intake and output (I&O).

Rationale -To establish Rapport. -For continuous pt. monitoring.

Evaluation Goal met. The patient displayed appropriat e urinary output, stable vital signs within the patients normal range and absence of edema.

Assess skin, face, dependent areas for edema

-Accurate I&O is necessary for determining renal function and fluid replacement needs and reducing risk of fluid overload -Edema occurs primarily in dependent tissues of the body, e.g., hands, feet, lumbosacral area, patient can gain up to 10 lb (4.5 kg) of fluid before pitting edema is detected.

Collaborative: Administer/ restrict fluids as indicated

Administer Medications as prescribe diuretics by the physician like diuretics

Administer

-Fluid managemen

grade of 1 out of 5 from the Grading Motor Strength test. V/S taken as follows: Temp: 36.5C PR: 83 bpm, 2+ RR: 20 cpm, bilateral chest expansio n. BP: 140/120 mmHg

Antihypertensive drugs as prescribed by the physician.

t is usually calculated to replace output from all sources plus estimated insensible losses. -Given early in oliguric phase of Renal Failure in an effort to convert to nonoliguric phase, flush the tubular lumen of debris, reduce hyperkalemi a, and promote adequate urine volume. -May be given to treat hypertensio n by counteractin g effects of decreased renal blood flow and/or circulating volme overload.