Medical Diagnosis: Renal Failure

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

Assessment Nursing Planning Interventions Evaluation

Diagnosis
Subjective: (none) Fluid Volume Short Term: 1. Establish rapport Short Term:
Excess R/T After 4-8 hours of 2. Monitor and record vital signs The patient shall have
Objective: decrease nursing 3. Assess possible risk factors demonstrated behaviors
Patient Glomerular interventions, 4. Monitor and record vital signs. to monitor fluid status
manifested: filtration Rate patient will 5. Assess patient’s appetite and reduce recurrence
 Edema and sodium demonstrate 6. Note amount/rate of fluid intake of fluid excess
 Hypertension retention behaviors to from all sources
 Weight gain monitor fluid status 7. Compare current weight gain with
 Pulmonary and reduce admission or previous stated Long Term:
congestion recurrence of fluid weight The patient shall have
(SOB, DOB) excess 8. Auscultate breath sounds manifested stabilized
 Oliguria 9. Record occurrence of dyspnea fluid volume AEB
 Distended 10. Note presence of edema. balance I & O, normal
jugular vein Long Term: 11. Measure abdominal girth for VS, stable weight, and
 Changes in After 3 days of changes. free from signs of
mental status nursing 12. Evaluate mentation for confusion edema.
intervention the and personality changes.
patient will 13. Observe skin mucous membrane.
manifest stabilize 14. Change position of client timely.
fluid volume AEB 15. Review lab data like BUN,
balance I & O, Creatinine, Serum electrolyte.
normal VS, stable 16. Restrict sodium and fluid intake if
weight, and free indicated
from signs of 17. Record I&O accurately and
edema. calculate fluid volume balance
18. Weigh client

19. Encourage quiet, restful

atmosphere.
20. Promote overall health measure.
Fluid volume excess r/t compromised regulatory mechanism (renal failure)

Assessment Nursing Planning Interventions Evaluation

Diagnosis
Subjective: Fluid volume Short Term: Independent Short Term:
“namamanas ako at excess r/t After 8 hrs of  Record accurate intake and After 8 hrs of nursing
nang hihina ako” avb compromised nursing output intervention goal met as
by the patient regulatory intervention the evidence by the patient
mechanism patient will display  Weight daily at same day, displayed appropriate
objective: (renal failure) appropriate urinary same scale, same time, and urinary output with
 generalize output with same clothing specific gravity, vital
edema specific gravity, signs with in normal
 patient vital signs with in  Assess skin, face, dependent range and absence of
reports of normal range and areas for edema edema
fatigue, absence of edema
weakness,  Plan oral fluid replacement with Long term goal after 4
and malaise Long term goal patient, within multiple days of nursing
 weight 53kg after 4 days of restrictions intervention goal met as
vital sign taken nursing evidence by the patient
as follows: intervention the displayed stable weight
 bp- patient will display from 53kg to 51kg
140/90mmHg stable weight from
 pr-60bpm 53kg to 51kg
 rr-20cpm
 T-36.7C
Impaired urinary elimination r/t glomerular malfiltration AEB impaired excretion of nitrogenous products secondary to renal failure

Assessment Nursing Planning Interventions Evaluation

Diagnosis
Subjective: Impaired urinary Short Term . Short Term
“Nahihirapan ako sa elimination r/t : After 2-3 hours : After 2-3 hours goal
pag ihi” avb the glomerular of nursing  Establish rapport. met as evidence by
patient malfiltration AEB interventions, the  Monitor and record vital signs to patient verbalized
impaired patient will verbalize obtain baseline data understanding of condition
objective: excretion of understanding  Assess pt’s general condition to
 Increase in nitrogenous of condition know the problem and interventions Long Term
lab results products should be prioritize : After 1-2 days
(BUN, secondary to Long Term  Review for laboratory test of nursing interventions goal
creatinine, renal failure : After 1-2 days for changes in renal function. met as evidence by he
uric acid of nursing  Establish realistic activity goal with patient participated in
level) as interventions, the client. measures to
evidence by: patient will participate  Determine clients pattern correct/compensate or
 Crea: in measures to of elimination defects
520umol/L correct/compensate  Palpate bladder
 BUN: 28mg/L or defects
 Uric acid:
488umol/L
 GFR: 15
 Oliguria as
evidence by
150ml/ 8
hours
 Urinary
retention