Ckd Ncp

NCP

Kong, Michael Robert ASSESSMENT

DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Independent SUBJECTIVE: “Namamanas ako at ang hina ng katawan ko” (I have edema and I feel very weak) as verbalized by the patient

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

Renal failure Decrease blood flow to kidneys Decrease perfusion in kidney

OBJECTIVE: • Venous distension • Generaliz ed edema • Patient reports of Fatigue, weakness, and malaise • V/S taken as follows T: 35˚C P: 50 R: 13 BP: 130/90

Decrease urinary output Water retention

After 8 hours of nursing intervention, the patient will display appropriate urinary output with specific gravity/laborator y studies near normal; stable weight, vital signs within patient’s normal range; and absence of edema.

• Record accurate intake and output (I&O).

• Accurate I&O is necessary for determining renal function and fluid replacement needs and reducing risk of fluid overload

• Weigh daily at same time of day, on same scale, with same equipment and clothing

• Daily body weight is best monitor of fluid status

• Assess skin, face, dependent areas for edema

Fluid volumes excess

• Plan oral fluid replacement with patient, within multiple restrictions

• Edema occurs primarily in dependent tissues of the body, e.g., hands, feet, lumbosacral area. Patient can gain up to 10 lb (4.5 kg) of fluid before pitting edema is detected • Helps avoid periods without fluids, minimizes boredom of limited choices, and reduces sense of

Goal met, patient has displayed appropriate urinary output with specific gravity/laborato ry studies near normal; stable weight, vital signs within patient’s normal range; and absence of edema.

Kong, Michael Robert

NCP Collaborative • Administer/restric t fluids as indicated.

• Administer medication as indicated Diuretics, e.g., furosemide (Lasix), mannitol (Osmitrol)

• Antihypertensive s, e.g., clonidine (Catapres)

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