ASSESSMENT SUBJECTIVE: masakit yong sa left waist ko sa likod isa yon sa mga nararamdaman ko as verbalized by the patient.

OBJECTIVE: V/S taken as follows T: 36.6 HR: 80 RR: 20 BP: 120/90

DIAGNOSIS Fluid Volume excess r/t Compromised regulatory mechanism (renal failure)

INFERENCE Renal failure Decrease blood flow to kidneys Decrease perfusion in kidney Decrease urinary output Water retention Fluid volumes excess

PLANNING After 8 hours of nursing intervention, the patient will display appropriate urinary output with specific gravity/laboratory studies near normal; stable weight, vital signs within patients normal range.

INTERVENTION Independent Record accurate intake and output (I&O). Weigh daily at same time of day, on same scale, with same equipment and clothing Plan oral fluid replacement with patient, within multiple restrictions Collaborative Administer/restrict fluids as indicated. Administer medication as indicated Diuretics, e.g., furosemide (Lasix), mannitol (Osmitrol) Antihypertensive, e.g., clonidine (Catapres)

RATIONALE Accurate I&O is necessary for determining renal function and fluid replacement needs and reducing risk of fluid overload Daily body weight is best monitor of fluid status Helps avoid periods without fluids, minimizes boredom of limited choices, and reduces sense of deprivation and thirst Fluid management is usually calculated to replace output from all sources plus estimated insensible losses Given early in oliguric phase of Renal Failure in an effort to convert to nonoliguric phase, flush the tubular lumen of debris, reduce hyperkalemia, and promote adequate urine volume. May be given to treat hypertension by counteracting

EVALUATION Goal met, patient has displayed appropriate urinary output with specific gravity/laborat ory studies near normal; stable weight, vital signs within patients normal range; and absence of edema.

effects of decreased renal blood flow and/or circulating volume overload.