Kong, Michael Robert NCP

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent
SUBJECTIVE: Fluid Volume Renal failure After 8 hours of Goal met,
“Namamanas excess r/t nursing  Record accurate  Accurate I&O is patient has
ako at ang hina Compromised intervention, the intake and output necessary for displayed
ng katawan ko” regulatory Decrease blood patient will (I&O). determining renal appropriate
(I have edema and mechanism flow to kidneys display function and fluid urinary output
I feel very weak) (renal failure) appropriate replacement needs with specific
as verbalized by urinary output and reducing risk of gravity/laborat
the patient Decrease with specific fluid overload ory studies
perfusion in gravity/laborator near normal;
kidney y studies near  Weigh daily at same  Daily body weight is stable weight,
OBJECTIVE: normal; stable time of day, on same best monitor of fluid vital signs
weight, vital scale, with same status within patient’s
 Venous Decrease signs within equipment and normal range;
distension urinary output patient’s normal clothing and absence
 Generalized range; and of edema.
edema absence of  Assess skin, face,  Edema occurs
 Patient Water retention edema. dependent areas for primarily in
reports of edema dependent tissues
Fatigue, of the body, e.g.,
weakness, Fluid volumes hands, feet,
and malaise excess lumbosacral area.
 V/S taken as Patient can gain up
follows to 10 lb (4.5 kg) of
fluid before pitting
T: 35˚C edema is detected
P: 50
R: 13  Plan oral fluid  Helps avoid periods
BP: 130/90 replacement with without fluids,
patient, within minimizes boredom
multiple restrictions of limited choices,
and reduces sense
of deprivation and
thirst
Kong, Michael Robert NCP

Collaborative

 Administer/restrict  Fluid management

fluids as indicated. is usually calculated
to replace output
from all sources
plus estimated
insensible losses

 Administer  Given early in

medication as oliguric phase of
indicated Renal Failure in an
Diuretics, e.g., effort to convert to
furosemide (Lasix), nonoliguric phase,
mannitol (Osmitrol) flush the tubular
lumen of debris,
reduce
hyperkalemia, and
promote adequate
urine volume.

 Antihypertensives,  May be given to

e.g., clonidine treat hypertension
(Catapres) by counteracting
effects of decreased
renal blood flow
and/or circulating
volume overload