Assessment Diagnosis Planning Intervention- Rationale Evaluation

Objective: Fluid Volume Long term: Accurately record intake Decrease in output
Excess related to Within 3 and output (I&O) noting to (to less than 400 ml
Abnormal compromised weeks, include hidden fluids per 24 hours) may
breath sounds: regulatory The patient such as IV antibiotic indicate acute failure,
crackles mechanism (renal will: additives, liquid especially in high-risk
failure as evidence Display medications, frozen treats, patients. Accurate
Altered electrol by generalized appropriate ice chips. Religiously monitoring of I&O is
ytes tissue edema, urinary output measure gastrointestinal necessary for
Decreased Hgb weight gain with specific losses and estimate determining renal
Edema gravity/laborat insensible losses function and fluid
Restlessness ory studies (sweating), including replacement needs
Shortness of near normal; wound drainage, and reducing risk of
breath; stable weight, nasogastric outputs, fluid overload. Do
orthopnea/dysp vital signs and diarrhea. note that
nea within hypervolemia usually
VS: patients occurs in anuric
BP: 130/90 normal range; phase of ARF and
RR: 18 and absence may mask the
PR: 98 of edema. symptoms.
Monitor urine specific Measures the
gravity. kidneys ability to
concentrate urine. In
intrarenal failure,
specific gravity is
usually equal to or
less than 1.010,
indicating loss of
ability to concentrate
the urine.
Weigh daily at same time Daily body weight is
of day, on same scale, with best monitor of fluid
same equipment and status. A weight gain
clothing. of more than 0.5
kg/day suggests fluid
retention.
Assess skin, face, Edema occurs
dependent areas for primarily in
edema. Evaluate degree of dependent tissues of
edema (on scale of +1 the body, (hands,
+4). 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.
Monitor heart rate (HR), BP, 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/orhypotension 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.
Auscultate lung and heart Fluid overload may
sounds. lead to pulmonary
edema and HF
evidenced by
development of
adventitious breath
sounds, extra heart
sounds.
Assess level of May reflect fluid
consciousness. Investigate shifts, accumulation
changes in mentation, of toxins, acidosis,
presence of restlessness. electrolyte
imbalances, or
developing hypoxia.

Patient: Cornello