2. What are four appropriate nursing interventions for this nursing diagnosis?
Close monitoring should be done for patients with fluid and electrolyte imbalances.
INTERVENTION
1. I&O. The nurse should monitor for fluid I&O
at least every 8 hours, or even hourly.
2. Daily weight. Assess the patient’s weight daily
to measure any gains or losses.
3. Vital signs. Vital signs should be closely
monitored
4. Physical exam. Physical exam is needed to
reinforce other data about a fluid or electrolyte
imbalance.
RATIONALE
1. Decrease in output (to less than 400 ml per 24
hours) may indicate acute failure, especially in
high-risk patients. Accurate monitoring of I&O is
necessary for determining renal function and fluid
replacement needs and reducing risk of fluid
overload. Do note that hypervolemia usually
occurs in anuric phase of ARF and may mask the
symptoms.
2. When a patient's chronic kidney disease has
progressed to where the kidneys have minimal to
no function at all, chronic renal failure occurs.
Because this condition affects how your body is
able to filter wastes and maintain calcium and
potassium balance, your body may not be able to
digest foods properly. This can result in weight
loss and inability to fully absorb nutrients from
food.
3. Tachycardia and hypertension can occur
because of: (1) failure of the kidneys to excrete
urine, (2) excess fluid resuscitation during efforts
to treat hypovolemia and/or hypotension or
convert oliguric phase of renal failure, (3) changes
in the renin-angiotensin system. Invasive
monitoring may be needed for assessing
intravascular volume, especially in patients with
poor cardiac function.
4. Edema can occur primarily in dependent tissues
of the body, (hands, feet, lumbosacral area).
Patient can gain up to 10 lb (4.5 kg) of fluid
before pitting edema is detected. Periorbital
edema may be a presenting sign of this fluid shift
because these fragile tissues are easily distended
by even minimal fluid accumulation