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    Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

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    Mr. white
    The patient presents with edema, weakness, and reports of fatigue and malaise. Based on the subjective and objective findings, the nurse diagnoses the patient with renal failure likely due to a compromised regulatory mechanism resulting in fluid volume excess. The plan is to monitor intake and output, administer fluids and medications as needed, and evaluate the patient's response based on urinary output, weight, and vital signs.

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    Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

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    Mr. white
    561 views2 pages
    The patient presents with edema, weakness, and reports of fatigue and malaise. Based on the subjective and objective findings, the nurse diagnoses the patient with renal failure likely due to a compromised regulatory mechanism resulting in fluid volume excess. The plan is to monitor intake and output, administer fluids and medications as needed, and evaluate the patient's response based on urinary output, weight, and vital signs.

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    -CKd NCP

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    The patient presents with edema, weakness, and reports of fatigue and malaise. Based on the subjective and objective findings, the nurse diagnoses the patient with renal failure likely due to a compromised regulatory mechanism resulting in fluid volume excess. The plan is to monitor intake and output, administer fluids and medications as needed, and evaluate the patient's response based on urinary output, weight, and vital signs.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    561 views2 pages

    Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

    Uploaded by

    Mr. white
    The patient presents with edema, weakness, and reports of fatigue and malaise. Based on the subjective and objective findings, the nurse diagnoses the patient with renal failure likely due to a compromised regulatory mechanism resulting in fluid volume excess. The plan is to monitor intake and output, administer fluids and medications as needed, and evaluate the patient's response based on urinary output, weight, and vital signs.

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    © All Rights Reserved
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    Kong, Michael Robert NCP

    ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION


    Independent
    SUBJECTIVE: Fluid Volume Renal failure After 8 hours of Goal met,
    “Namamanas excess r/t nursing  Record accurate  Accurate I&O is patient has
    ako at ang hina Compromised intervention, the intake and output necessary for displayed
    ng katawan ko” regulatory Decrease blood patient will (I&O). determining renal appropriate
    (I have edema and mechanism flow to kidneys display function and fluid urinary output
    I feel very weak) (renal failure) appropriate replacement needs with specific
    as verbalized by urinary output and reducing risk of gravity/laborat
    the patient Decrease with specific fluid overload ory studies
    perfusion in gravity/laborator near normal;
    kidney y studies near  Weigh daily at same  Daily body weight is stable weight,
    OBJECTIVE: normal; stable time of day, on same best monitor of fluid vital signs
    weight, vital scale, with same status within patient’s
     Venous Decrease signs within equipment and normal range;
    distension urinary output patient’s normal clothing and absence
     Generalized range; and of edema.
    edema absence of  Assess skin, face,  Edema occurs
     Patient Water retention edema. dependent areas for primarily in
    reports of edema dependent tissues
    Fatigue, of the body, e.g.,
    weakness, Fluid volumes hands, feet,
    and malaise excess lumbosacral area.
     V/S taken as Patient can gain up
    follows to 10 lb (4.5 kg) of
    fluid before pitting
    T: 35˚C edema is detected
    P: 50
    R: 13  Plan oral fluid  Helps avoid periods
    BP: 130/90 replacement with without fluids,
    patient, within minimizes boredom
    multiple restrictions of limited choices,
    and reduces sense
    of deprivation and
    thirst
    Kong, Michael Robert NCP

    Collaborative

     Administer/restrict  Fluid management


    fluids as indicated. is usually calculated
    to replace output
    from all sources
    plus estimated
    insensible losses

     Administer  Given early in


    medication as oliguric phase of
    indicated Renal Failure in an
    Diuretics, e.g., effort to convert to
    furosemide (Lasix), nonoliguric phase,
    mannitol (Osmitrol) flush the tubular
    lumen of debris,
    reduce
    hyperkalemia, and
    promote adequate
    urine volume.

     Antihypertensives,  May be given to


    e.g., clonidine treat hypertension
    (Catapres) by counteracting
    effects of decreased
    renal blood flow
    and/or circulating
    volume overload

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