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Student Nurses’ Community

Student Nurses’ Community

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Nursing   nursing care plan renal failure Slide 1 Nursing   nursing care plan renal failure Slide 2
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Nursing nursing care plan renal failure

  1. 1. Student Nurses’ Community NURSING CARE PLAN – Renal Failure 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/laborato the patient Decrease with specific fluid overload ry studies near perfusion in gravity/laborator normal; stable kidney y studies near • Weigh daily at same • Daily body weight is weight, vital OBJECTIVE: normal; stable time of day, on same best monitor of fluid signs within weight, vital scale, with same status patient’s • Venous Decrease signs within equipment and normal range; distension urinary output patient’s normal clothing and absence of • Generalized range; and 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
  2. 2. Student Nurses’ Community thirst 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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