Assessment

Objective:

Increase in
Lab results
(BUN,
Creatinine)
Edema on
the hand

Nursing
Diagnosis

Goals

Short Term
Altered Renal After 2-3 hours
Perfusion
of NI, the
patient will
related to
demonstrate
Glomerular
Malfunction participation in
as manifested her
by Increase in recommended
treatment
,BUN
program.
Long Term
After 2-3 days of
NI, the patient
will demonstrate
behavior/lifestyl
e changes to
prevent
complications

Interventions

1. Establish rapport
2. Monitor and
record vital signs.
3. Assess patients
.general condition
4. Note
characteristic of
urine: measure
urine specific
gravity.

Rationale

Evaluation

To get the
cooperation
.of the patient
To obtain
baseline data

The goal is
partially met
as evidenced
by patient
participate in
the
recommended
treatment for
.her

To obtain
baseline data
To assess
renal
.impairment

5. Measure urine
output on a
regular schedule
and weigh daily

To assess
renal
perfusion and
function

6. Observe for

To note degree

dependent
generalized
edema.

Assessment

Nursing

Goals

Interventions

of impairment
of renal
function

Rationale

Evaluation

Diagnosis
Subjective:

"I feel like

my whole
body is
swelling. I
cannot
urinate, and I
feel so weak"
as verbalized
by patient.

Long Term
Fluid Volume
Excess related
to decreased
urine output
as manifested
by edema ,
vital signs
change
( BP )

After 2 days of NI,

Patient will
demonstrate
behaviors to
monitor fluid
status and
reduce
recurrence of
fluid excess

Short Term
Objective:

-decrease
urine output
(less than
400)
-increase
blood
pressure
(161/89mmH

After 2 hours of
NI, Patient will
manifest stabilize
fluid volume,
balance I & O,
normal VS and
free from signs of
edema

1. Assess possible
risk factors
2. Monitor and
record vital signs.
3. Note amount/rate
of fluid intake
from all sources.

4. Compare current
weight gain with
previous stated
weight
5. Note presence of
edema
6. Teach the patient
to restrict sodium
and fluid intake.
7. Record I&O

To assess
precipitating
and causative
.factors
To obtain
baseline data
To prevent
fluid overload
and monitor
intake and
output
To monitor
fluid retention
and evaluate
degree of
excess
To determine
fluid retention
To lessen fluid

The goal is
partially met as
evidenced by
stable vital
,sings
free from sings
of edema,
normal urine
output (more
than 400ml)
and ideal body
weight is
.maintained

g)
-LF hand
edema

accurately and
calculate fluid
volume balance

retention and
.overload
To monitor
kidney
function and
.fluid retention