CUESNURSING DIAGNOSIS

GOAL/OBJECTIVES

INTERVENTIONS RATIONALEEVALUATION

EdemaHypertensionOliguriaAltered mental statusUrinary RetentionRestlessness

Fluid Volume Excess R/T decrease glomerular filtration rate and sodium and urinary retention

After 8 hours of nursing intervention the patient will be able to manifest stabilize fluid volume I & O, normal VS and decreased level of edema.

Accurately record intake and output (I&O) noting to include “hidden” fluids such as IV antibiotic additives, liquid medications, frozen treats, ice chips. Religiously measure gastrointestinal losses and estimate insensible losses (sweating), including wound drainage, nasogastric outputs, and diarrhea.

Monitor urine specific gravity.

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

Daily body weight is best monitor of fluid status. A weight gain of more than 0.5 kg/day suggests fluid retention.

Assess skin, face, dependent areas for edema. Evaluate degree of edema (on scale of +1–+4).

Decrease in output (to less than 400 ml per 24 hours) may indicate acute failure, especially in high-risk patients. Accurate monitoring of I&O is necessary for determining renal function and fluid replacement needs and reducing risk of fluid overload. Do note that hypervolemia usually occurs in anuric phase of ARF and may mask the symptoms.

Measures the kidney’s ability to concentrate urine. In intrarenal failure, specific gravity is usually equal to or less than 1.010, indicating loss of ability to concentrate the urine.Weigh daily at same time of day, on same scale, with same equipment and clothing.Daily body weight is best monitor of fluid status. A weight gain of more than 0.5 kg/day suggests

After 8 hours of nursing intervention the patient was able to manifest stabilize fluid volume I & O, normal VS and decreased level of edema.

Edema occurs primarily in dependent tissues of the body, (hands, feet, lumbosacral area). Patient can gain up to 10 lb (4.5 kg) of fluid before pitting edema is detected. Periorbital edema may be a presenting sign of this fluid shift because these fragile tissues are easily distended by even minimal fluid accumulation.Monitor heart rate (HR), BP, and JVD/CVP.Tachycardia and hypertension can occur because of: (1) failure of the kidneys to excrete urine, (2) excess fluid resuscitation during efforts to treat hypovolemia and/or hypotension or convert oliguric phase of renal failure, (3) changes in the renin-angiotensin system. Invasive monitoring may be needed for assessing intravascular volume, especially in patients with poor cardiac function.Auscultate lung and heart sounds.Fluid overload may lead to pulmonary edema and HF evidenced by development of adventitious breath sounds, extra heart sounds.Assess level of consciousness. Investigate changes in mentation, presence of restlessness.May reflect fluid shifts, accumulation of toxins, acidosis, electrolyte imbalances, or

fluid retention.Assess skin, face, dependent areas for edema. Evaluate degree of edema (on scale of +1–+4).Edema occurs primarily in dependent tissues of the body, (hands, feet, lumbosacral area). Patient can gain up to 10 lb (4.5 kg) of fluid before pitting edema is detected. Periorbital edema may be a presenting sign of this fluid shift because these fragile tissues are easily distended by even minimal fluid accumulation.Monitor heart rate (HR), BP, and JVD/CVP.Tachycardia and hypertension can occur because of: (1) failure of the kidneys to excrete urine, (2) excess fluid resuscitation during efforts to treat hypovolemia and/or hypotension or convert oliguric phase of renal failure, (3) changes in the renin-angiotensin system. Invasive monitoring may be needed for assessing intravascular volume, especially in patients with poor cardiac function.Auscultate lung and heart sounds.Fluid overload may lead to

developing hypoxia.Scatter desired beverages throughout the 24-hour period and give various offering (hot, cold, frozen).Helps avoid periods without fluids, minimizes boredom of limited choices, and reduces sense of deprivation and thirst.Correct any reversible cause of ARF: replace blood loss, maximize cardiac output, discontinue nephrotoxic drug, relieve obstruction via surgery.Kidneys may be able to return to normal functioning, preventing or limiting residual effects.Use appropriate safety measures (raising side rails and restraints.Patient with CNS involvement may be dizzy and/or confused.Monitor diagnostic studies:  Blood urea nitrogen (BUN), creatinine (cr)BUN assess management of renal dysfunction. Both values may increase but creatinine is a better indicator of renal function because it is not affected by hydration, diet, and tissue catabolism. Dialysis is usually indicated if ratio is higher than 10:1 or if therapy fails to indicate fluid overload or metabolic acidosis.

pulmonary edema and HF evidenced by development of adventitious breath sounds, extra heart sounds.Assess level of consciousness. Investigate changes in mentation, presence of restlessness.May reflect fluid shifts, accumulation of toxins, acidosis, electrolyte imbalances, or developing hypoxia.Scatter desired beverages throughout the 24-hour period and give various offering (hot, cold, frozen).Helps avoid periods without fluids, minimizes boredom of limited choices, and reduces sense of deprivation and thirst.Correct any reversible cause of ARF: replace blood loss, maximize cardiac output, discontinue nephrotoxic drug, relieve obstruction via surgery.Kidneys may be able to return to normal functioning, preventing or limiting residual effects.Use appropriate safety measures (raising side rails and restraints.Patient with CNS involvement may be dizzy and/or confused.

Urine sodium and Cr.In ATN, tubular functional integrity is lost and sodium resorption is impaired, resulting in increased sodium excretion. Urine creatinine is usually decreased as serum creatinine elevates.Serum sodium.Hyponatremia may result from fluid overload (dilutional) or kidney’s inability to conserve sodium. Hypernatremia indicates total body water deficit.Serum potassium.Lack of renal excretion and/or selective retention of potassium to excrete excess hydrogen ions leads to hyperkalemia, requiring prompt intervention.Hb/Hct.Decreased values may indicate hemodilution (hypervolemia) however, during prolonged failure, anemia frequently develops as a result of RBC loss. Other possible causes (active or occult hemorrhage) should also be evaluated.Serial chest x-rays.Increased cardiac size, prominent pulmonary vascular markings, pleural effusion, congestion indicate acute responses to fluid overload or chronic changes associated with renal and heart failure.

Monitor diagnostic studies:  Blood urea nitrogen (BUN), creatinine (cr)BUN assess management of renal dysfunction. Both values may increase but creatinine is a better indicator of renal function because it is not affected by hydration, diet, and tissue catabolism. Dialysis is usually indicated if ratio is higher than 10:1 or if therapy fails to indicate fluid overload or metabolic acidosis.Urine sodium and Cr.In ATN, tubular functional integrity is lost and sodium resorption is impaired, resulting in increased sodium excretion. Urine creatinine is usually decreased as serum creatinine elevates.Serum sodium.Hyponatremia may result from fluid overload (dilutional) or kidney’s inability to conserve sodium. Hypernatremia indicates total body water deficit.Serum potassium.Lack of renal excretion and/or selective retention of potassium to

Administer and/or restrict fluids as indicated.Fluid management is usually calculated to replace output from all sources plus estimated insensible losses (metabolism, diaphoresis). Prerenal failure (azotemia) is treated with volume replacement and/or vasopressors. The oliguric patient with adequate circulating volume or fluid overload who is unresponsive to fluid restriction and diuretics requires dialysis. Note: During oliguric phase, “push/pull” therapy (push IV fluids and diurese with diuretics) may be tried to stimulate kidney function.Administer medication as indicated: Diuretics:  furosemide (Lasix), bumetanide (Bumex), torsemide (Demadex), mannitol (Osmitrol).Given early in oliguric phase of ARF in an effort to convert to non-oliguric phase, flush the tubular lumen of debris, reduce hyperkalemia, and promote adequate urine volume.Antihypertensives: clonidine (Catapres), methyldopa (Aldomet), prazosin (Minipress).May be given to treat hypertension by counteracting effects of decreased renal blood flow and/or circulating volume overload.

excrete excess hydrogen ions leads to hyperkalemia, requiring prompt intervention.Hb/Hct.Decreased values may indicate hemodilution (hypervolemia) however, during prolonged failure, anemia frequently develops as a result of RBC loss. Other possible causes (active or occult hemorrhage) should also be evaluated.Serial chest x-rays.Increased cardiac size, prominent pulmonary vascular markings, pleural effusion, congestion indicate acute responses to fluid overload or chronic changes associated with renal and heart failure.Administer and/or restrict fluids as indicated.Fluid management is usually calculated to replace output from all sources plus estimated insensible losses (metabolism, diaphoresis). Prerenal failure (azotemia) is treated with volume replacement and/or vasopressors. The oliguric patient with adequate circulating volume or fluid

Calcium channel blockers.Given early in nephrotoxic ATN to reduce influx of calcium into kidney cells, thereby helping to maintain cell integrity and improve GFR.Prostaglandins.Vasodilatory effect may improve circulating volume and reestablish renal blood flow to aid in clearing nephrotoxic agents from nephrons.Insert indwelling catheter, as indicated.Catheterization excludes lower tract obstruction and provides means of accurate monitoring of urine output during acute phase; however, indwelling catheterization may be contraindicated because of increased risk of infection.Prepare for dialysis as indicated: hemodialysis, peritoneal dialysis, or continuous renal replacement therapy (CRRT).Done to correct volume overload, electrolyte and acid-base imbalances, and to remove toxins. The type of dialysis chosen for ARF depends on the degree of hemodynamic compromise and patient’s ability to withstand the procedure.During peritoneal dialysis, position the patient carefully: elevate the head of the bed.Doing so would reduce the pressure on the

overload who is unresponsive to fluid restriction and diuretics requires dialysis. Note: During oliguric phase, “push/pull” therapy (push IV fluids and diurese with diuretics) may be tried to stimulate kidney function.Administer medication as indicated: Diuretics:  furosemide (Lasix), bumetanide (Bumex), torsemide (Demadex), mannitol (Osmitrol).Given early in oliguric phase of ARF in an effort to convert to non-oliguric phase, flush the tubular lumen of debris, reduce hyperkalemia, and promote adequate urine volume.Antihypertensives: clonidine (Catapres), methyldopa (Aldomet), prazosin (Minipress).May be given to treat hypertension by counteracting effects of decreased renal blood flow and/or circulating volume overload.Calcium channel blockers.Given early in nephrotoxic ATN to reduce influx of calcium into kidney cells, thereby helping to maintain cell integrity and

diaphragm and can aid in respiration.Watch out for complications such as peritonitis, atelectasis, hypokalemia, pneumonia and/or shock.These complications are common for patients undergoing peritoneal dialysis ish rapport

Monitor and record vital signs

Assess possible risk factors

Monitor and record vital signs.

Note amount/rate of fluid intake from all sources

Compare current weight gain with admission or previous stated weight

Auscultate breath sounds

Record occurrence of dyspnea

Note presence of edema.

Change position of client timely.

improve GFR.Prostaglandins.Vasodilatory effect may improve circulating volume and reestablish renal blood flow to aid in clearing nephrotoxic agents from nephrons.Insert indwelling catheter, as indicated.Catheterization excludes lower tract obstruction and provides means of accurate monitoring of urine output during acute phase; however, indwelling catheterization may be contraindicated because of increased risk of infection.Prepare for dialysis as indicated: hemodialysis, peritoneal dialysis, or continuous renal replacement therapy (CRRT).Done to correct volume overload, electrolyte and acid-base imbalances, and to remove toxins. The type of dialysis chosen for ARF depends on the degree of hemodynamic compromise and patient’s ability to withstand the procedure.During peritoneal dialysis, position the patient carefully:

Review lab data like BUN, Creatinine, Serum electrolyte.

Restrict sodium and fluid intake if indicated

Record I&O accurately and calculate fluid volume balance

Administer medication as ordered by the physician

elevate the head of the bed.Doing so would reduce the pressure on the diaphragm and can aid in respiration.Watch out for complications such as peritonitis, atelectasis, hypokalemia, pneumonia and/or shock.These complications are common for patients undergoing peritoneal dialysis

CUESNURSING DIAGNOSIS

GOAL/OBJECTIVES

INTERVENTIONS RATIONALE EVALUATION

Limited ROMBody weaknessAltered level of consciousness

Impaired physical mobility related to Neuromuscular involvement: weakness, evidenced by Inability to move within the physical environment; impaired coordination; limited range of motion; decreased muscle strength

After 8 hours of nursing intervention the patient will be able to maintain/increase strength and function of affected or compensatory body part.

After 8 hours of nursing intervention the patient will be able to maintain skin integrity.

Change positions at least every 2 hr (supine, side lying) and possibly more often if placed on affected side.

Place pillow under axilla to abduct arm

Elevate arm and hand

Observe affected side for color, edema, or other signs of compromised circulation.

Inspect skin regularly, particularly over bony prominences. Gently massage any reddened areas

Assist patient with exercise and perform ROM exercises for both the affected and unaffected sides.

Reduces risk of tissue injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown.

Prevents adduction of shoulder and flexion of elbow.

Promotes venous return

Edematous tissue is more easily traumatized and heals more slowly.

Pressure points over bony prominences are most at risk for decreased perfusion.

Aids in retraining neuronal pathways, enhancing proprioception and motor response.

After 8 hours of nursing intervention the patient was able to maintain/increase strength and function of affected or compensatory body part.

After 8 hours of nursing intervention the patient was able to maintain skin integrity.

CUESNURSING DIAGNOSIS

GOAL/OBJECTIVES

INTERVENTIONS RATIONALE EVALUATION

Limited ROMBody weaknessChanges in mental statusUrinary RetentionAltered level of consciousness

Ineffective cerebral tissue perfusion related to interruption of blood flow secondary to CVA

After 8 hours of nursing intervention the patient will be able to display decrease signs of ineffective tissue perfusion as evidence by gradual improvement of vital signs

Monitor vital signs

Check capillary refill and conjunctiva for paleness

elevate head of bed to 30 degrees as ordered Avoid neck flexion and extreme hip/knee extension

Provide and maintain oxygen as ordered Perform GCS monitoring as ordered 

Administer medications as ordered

To have a baseline data, assess changes in neurologic status

To determine blood circulation 

To promote circulation  To avoid obstruction of arterial and venous blood flow

Aids in difficulty of breathing

To detect changes indicative of worsening or improving condition

To promote wellness

After 8 hours of nursing intervention the patient was able to display decrease signs of ineffective tissue perfusion as evidence by gradual improvement of vital signs