Priority Nursing Diagnosis 1:

Assessment: The RN will assess the patient’s body for edema Q8H.
Rationale: Edema is fluid building up within the body and indicates the body is overloaded.
Monitoring: The RN will monitor the patient’s fluid volume status by taking a daily weight at the same
time using the same bed scale.
Rationale: Body weight is a great way to measure fluid excess and deficit.
Medication: The RN will administer 25gm of albumin human 25% to be infused over 1 hour q6hr for the
next 48 hours per provider order.
Rationale: Albumin will pull the excess fluid within the third space (in the tissues) into the vasculature.
Pulling the fluid into the vasculature reduces edema. By increasing the circulatory fluid, the patient can
offload it by having it pulled off through hemodialysis.
Treatment: The RN will ensure the patient gets their anticipated dialysis treatment on the scheduled
days per provider order.
Rationale: The main function of dialysis is to filter the blood and perform the job of the kidneys,
however it can also help regulate the fluid within the patient’s circulatory system.
Education:
Collaboration: The RN will collaborate with the dietician to create a renal diet plan for the patient.
Rationale: A renal diet provides the patient with a nutritious meal while being low in sodium. Excess
sodium promotes fluid retention and by decreasing the intake, we do not encourage excess fluid
retention.

Priority Nursing Diagnosis 2: Risk for Acute Confusion pg 606 in Nursing Care Plans
Assessment:
Monitoring:
Medication:
Treatment:
Education:
Collaboration:

Priority Nursing Diagnosis 3: Risk for Bleeding

Assessment:
Monitoring:
Medication:
Treatment:
Education:
Collaboration:

Priority Nursing Diagnosis 4: Ineffective Health Maintenance

Assessment:
Monitoring:
Medication:
Treatment:
Education:
Collaboration: