Medical Diagnosis: Renal Failure

Problem: Fluid Volume Excess RT Decreased Glomerular Filtration Rate and Sodium Retention

Assessment Nursing Scientific Planning Interventions Rationale Evaluation

Diagnosis Explanation

Subjective: Fluid Volume Renal disorder Short Term: 1. Establish 1. To assess Short Term:
(none) Excess R/T impairs After 4-8 hours of rapport precipitati The patient shall
decrease glomerular nursing ng and have
causative
Glomerular filtration that interventions, demonstrated
factors.
Objective: filtration Rate resulted to fluid patient will 2. Monitor behaviors to
and sodium overload. With demonstrate and record 2. To obtain monitor fluid
Patient retention fluid volume behaviors to vital signs baseline status and
manifested: excess, monitor fluid data reduce
hydrostatic status and 3. Assess recurrence of
• Edema pressure is reduce possible 3. To obtain fluid excess
• Hypertension risk factors baseline
higher than the recurrence of
• Weight gain data
usual pushing fluid excess
• Pulmonary excess fluids into
congestion the interstitial 4. Monitor Long Term:
4. To note for
(SOB, DOB) spaces. Since and record presence The patient shall
• Oliguria fluids are not Long Term: vital signs. of nausea have manifested
• Distended reabsorbed at After 3 days of and stabilized fluid
jugular vein nursing vomiting volume AEB
the venous end, 5. Assess
• Changes in fluid volume intervention the balance I & O,
patient’s 5. To prevent
mental status overloads the patient will normal VS, stable
appetite fluid
lymph system manifest stabilize overload weight, and free
Patient may fluid volume AEB from signs of
and stays in the and
manifest: balance I & O, monitor edema.
interstitial spaces
leading the normal VS, stable intake and
weight, and free 6. Note output
patient to have amount/ra
edema, weight from signs of
te of fluid 6. To monitor
gain, pulmonary edema.
intake fluid
congestion and from all retention

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HPN at the same sources and
time due to evaluate
decrease GFR, degree of
7. Compare excess
nephron
current
hyperthrophized weight
leading to gain with 7. For
decrease ability admission presence
of the kidney to or of crakles
concentrate previous or
urine and stated congestion
weight
impaired
8. Auscultate
excretion of fluid breath 8. To
thus leading to sounds evaluate
oliguria/anuria. degree of
9. Record excess
occurrence
of dyspnea 9. To
determine
10.Note fluid
presence retention
of edema.
10.May
11.Measure indicate
abdominal increase in
girth for fluid
changes. retention

12.Evaluate
mentation 11.May
for indicate
confusion cerebral
and edema.
personality
changes.
12.To
13.Observe evaluate

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 skin degree of
mucous fluid
membrane excess.
.

14.Change
position of 13.To prevent
client pressure
timely. ulcers.

14.To monitor
15.Review lab fluid and
data like electrolyte
BUN, imbalance
Creatinine, s
Serum
electrolyte 15.To lessen
. fluid
retention
16.Restrict and
sodium overload.
and fluid
intake if
indicated

17.Record 16.To monitor

I&O kidney
accurately function
and and fluid
calculate retention.
fluid 17.Weight
volume gain
balance indicates
fluid
18.Weigh retention
client or edema.

18.Weight

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 19.Encourage gain may
quiet, indicate
restful fluid
atmospher retention
e. and
edema.
20.Promote 19.To
overall conserve
health energy
measure. and lower
tissue
oxygen
demand.
20.To
promote
wellness.

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