*

CLUES

* August 11, 2012 * August 14, 2012 HGB = 75g/dL (120-170; low) (+)edema on both legs HCT=.21 (.37-.54; low) (+) crackles Creatinine = 6.31mg/dL (0.5-1.2; low) (+) restlessness Ionized calcium = 1.0mmol/dL (1.12-1.32 ;

low) Na = 135mmol/L (137-147; low) Pulmonary congestion Minimal pleural effusion is noted on left side
(+) oliguria CUE

* August 12 , 2012
-intake exceeds output (I=1000ml, O=830ml)

* August 14
nahihirapan ako huminga, lalo kapag nakahiga

* August 13, 2012

-intake exceeds output (I=1130ml, O=830ml)

*Excess Fluid Volume related to

compromised regulatory mechanism due to chronic kidney problem as evidenced by altered sodium and calcium levels, decreased hemoglobin and hematocrit, increased creatinine, oliguria, edema, crackles, restlessness, orthopnea, pulmonary congestion, and pleural effusion.

* Glomerulonephritis damages the glomeruli, letting

protein and sometimes red blood cells leak into the urine. Sometimes a glomerulonephritis interferes with the clearance of waste products by the kidney, so they begin to build up in the blood. In normal blood, albumin acts like a sponge, drawing extra fluid from the body into the bloodstream, where it remains until the kidneys remove it. But when albumin leaks into the urine, the blood loses its capacity to absorb extra fluid from the body. Fluid can accumulate outside the circulatory system in the face, hands, feet, or ankles and cause swelling.

*
(www.kidney.niddk.nih.gov, March, 2012) (Eric Cohen MD, et. Al, May 2012 retrieved from www. mcw.edu)

After 5 hours of nursing interventions, the patient will be able to:

*Verbalize willingness about sodium and fluid restriction. *Enumerate ways to reduce discomfort of fluid restrictions *Verbalize willingness to record intake and output. *Be safe from injuries like falls which may be caused by *Enumerate ways in reducing edema: ice, activity,
elevation, compression stockings.

like frequent oral care, chewing candy or gum, and use of lip balm.

changes in mentation due to altered electrolyte levels.

After 2 weeks of nursing interventions, the patient will be able to: *Adhere to sodium and fluid restriction, and intake and output monitoring. *Be able to use interventions to reduce discomfort of fluid restrictions like frequent oral care, chewing candy or gum, and use of lip balm. *Demonstrate ways in reducing edema: ice, compression stockings, elevation, activity. *Have stabilized fluid volume as evidenced by balanced intake and output, vital signs within normal range, stable weight, and decreased or absent edema.

1. Advise to restrict fluid and sodium intake as indicated.

1. Increased sodium would retain fluid, further increase in fluid intake would worsen the problem. 2.To still add flavor to clients food and prevent loss of appetite.

2. Suggest substitutes for salt like lemon and oregano.

3. Discuss hidden sources of fluid like ice cream, soups, and gelatin.

3.To maintain fluid restriction and correct the imbalance.

4. Suggest ways to reduce discomfort caused by fluid restriction: Use lip balm Chew gum or candy Frequent oral care

4. Moistens the lips and oral mucosa. 5. Evaluates effectiveness of interventions, and allows for client and family participation towards care. 6. To facilitate movement of diaphragm thus improving respiratory effort.

5. Record intake and output accurately, and teach the client and her family how to do so. 6. Place client in semi-fowlers position.

7. Remind about the need to ambulate and/ or have frequent position changes. 8. Maintain safety precautions like keeping the side-rails up, and ensuring that client would not be left alone. 9. Elevate edematous extremities and change position frequently.

7. To prevent fluid stasis and reduce risk of tissue injury. 8. Altered electrolyte levels may cause altered motor responses, mentation and level of consciousness. 9. To reduce tissue pressure and risk of skin breakdown.

10. Teach client ways to reduce leg edema: Avoid standing or sitting in one place too long. Pumping the feet up and down at the ankle to move the calf muscle as exercise helps too.

10. To promote client participation in care Activity and exercise increases circulation and pumps excess fluids from the legs.

Elevation techniques put gravity to Elevate the legs higher than the level use by using its force to draw fluids of the heart for 20-minute periods 3-4 from the legs and up to the heart. times throughout the day. Applies pressure to the legs to Use of compression stockings. stimulate circulation and move fluid from the tissues. Use of ice packs wrapped in towels applied to the swollen area for about Ice helps to constrict the blood 15-20 minutes vessels and reduce the amount of fluid that is deposited.