Medical Diagnosis: Renal Failure Problem: Fluid Volume Excess RT Decreased Glomerular Filtration Rate and Sodium Retention

Assessment Subjective: (none) Objective: Patient manifested:

Nursing Diagnosis Fluid Volume Excess R/T decrease Glomerular filtration Rate and sodium retention

congestion (SOB, DOB)

vein status Patient may manifest:

Scientific Explanation Renal disorder impairs glomerular filtration that resulted to fluid overload. With fluid volume excess, hydrostatic pressure is higher than the usual pushing excess fluids into the interstitial spaces. Since fluids are not reabsorbed at the venous end, fluid volume overloads the lymph system and stays in the interstitial spaces leading the patient to have edema, weight gain, pulmonary congestion and HPN at the same time due to decrease GFR, nephron hyperthrophized leading to decrease ability of the kidney to concentrate urine

Planning Short Term: After 4-8 hours of nursing interventions, patient will demonstrate behaviors to monitor fluid status and reduce recurrence of fluid excess Long Term: After 3 days of nursing intervention the patient will manifest stabilize fluid volume AEB balance I & O, normal VS, stable weight, and free from signs of edema.

Interventions 1. Establish rapport 2. Monitor and record vital signs 3. Assess possible risk factors 4. Monitor and record vital signs. 5. Assess patients appetite 6. Note amount/rate of fluid intake from all sources 7. Compare current weight gain with admission or previous stated weight

Rationale 1. To assess precipitating and causative factors. 2. To obtain baseline data 3. To obtain baseline data 4. To note for presence of nausea and vomiting 5. To prevent fluid overload and monitor intake and output 6. To monitor fluid retention and evaluate degree of excess 7. For presence of crackles or congestion

Evaluation Short Term: The patient shall have demonstrated behaviors to monitor fluid status and reduce recurrence of fluid excess Long Term: The patient shall have manifested stabilized fluid volume AEB balance I & O, normal VS, stable weight, and free from signs of edema.

and impaired excretion of fluid thus leading to oliguria/anuria.

8. To evaluate degree of excess 8. Auscultate 8. To evaluate breath sounds degree of excess 9. To determine fluid retention 9. Record 9. To determine occurrence of fluid retention 10. May indicate dyspnea increase in fluid 10. May indicate retention 10. Note presence increase in fluid of edema. retention 11. May indicate cerebral edema. 11. Measure 11. May indicate abdominal girth for cerebral edema. 12. To evaluate changes. degree of fluid 12. To evaluate excess. 12. Evaluate degree of fluid mentation for excess. 13. To prevent confusion and pressure ulcers. personality 13. To prevent changes. pressure ulcers. 14. To monitor fluid andTo electrolyte 13. Observe skin 14. monitor fluid imbalances mucous membrane. and electrolyte imbalances 14. Change position 15. To lessen fluid retention andfluid of client timely. 15. To lessen overload. retention and 15. Review lab data overload. 16. To monitor like BUN, kidney function Creatinine, Serum 16. To monitor electrolyte. kidney function and fluid retention. 16. Restrict sodium 17. Weight gain and fluid intake if indicates fluid retention or edema. indicated 18. Weight gain may indicate fluid 17. Record I&O retention and accurately and edema. calculate fluid

volume balance 18. Weigh client 19. Encourage quiet, restful atmosphere. 20. Promote overall health measure.

19. To conserve energy and lower tissue oxygen demand. 20. To promote