Nursing crib.com nursing care plan renal failure

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1. Student Nurses’ Community
NURSING CARE PLAN – Renal Failure
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
“Namamanas
ako at ang hina
ng katawan ko”
(I have edema and
I feel very weak)
as verbalized by
the patient
OBJECTIVE:
·Venous
distension
·Generalized
edema
·Patient
reports of
Fatigue,
weakness,
and malaise
·V/S taken as
follows
T: 35˚C
P: 50
R: 13
BP: 130/90
Fluid Volume
excess r/t
Compromised
regulatory
mechanism
(renal failure)
Renal failure
Decrease blood
flow to kidneys
Decrease
perfusion in
kidney
Decrease
urinary output
Water retention
Fluid volumes
excess
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.
Independent
·Record accurate
intake and output
(I&O).
·Weigh daily at same
time of day, on same
scale, with same
equipment and
clothing
·Assess skin, face,
dependent areas for
edema
·Plan oral fluid
replacement with
patient, within
multiple restrictions
·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
·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 deprivation and
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.

2. Student Nurses’ Community
Collaborative
·Administer/restrict
fluids as indicated.
·Administer
medication as
indicated
Diuretics, e.g.,
furosemide (Lasix),
mannitol (Osmitrol)
·Antihypertensives,
e.g., clonidine
(Catapres)
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