Assessment Nursing Diagnosis Scientific Planning Intervention Rationale Evaluation

Explanation

Excess Fluid Goal:

Volume related to After 3 days of
decreased urine nursing intervention
output and the client will
compromised experience weight
regulatory gain less than 2-3
mechanism of the pounds on each day.
kidney as
manifested by
edema Short Term Goal:

After Nursing
Intervention the
client will be able to: INDEPENDENT
NURSING ACTIONS:
1. Verbalize 1. Discuss the following
understanding of the management needed to
management assesses increasing fluid
needed to assess volume:
increasing fluid a. Vital Sign assessment a. Signs of fluid excess
volume. (BP,RR,PR,TEMP) are elevated BP,
tachycardia, and
tachypnea. Elevated BP
is caused by sodium
retention and increased
intracellular fluid
volume
(Nursing Care Plans,
pg.852)

b.Assessment for other b.

signs of fluid volume
overload; edema,
weight gain,
distended neck vein,
orthopnea
 c. Assess for patient’s c. Excess fluid and
compliance with sodium intake can lead
dietary and fluid to fluid volume excess in
restrictions the ESRD patient
(Nursing Care Plans pg.
852)

d. Assess weight at d. To assess the

every visit before effectiveness of
and after dialysis treatment and
(weight gain not to monitoring of fluid
exceed 2 to 3 volume retention
pounds) (Nursing Care Plans
pg. 852)

2. Verbalize 2. Discuss the

understanding of following measures to
the measures to prevent and lessen
prevent and lessen fluid volume excess
fluid volume excess
a. Have patient sit up a.This maintains
if she complains of optimal positioning for
shortness of air exchange
breath (Nursing Care Plans
pg. 852)

b. Advise patient to b. This prevent and

elevate feet when lessen fluid
sitting down accumulation in
lower extremities
(Nursing Care Plans
pg. 852)
c. Instruct the patient c. Intake of fluid up to
regarding 500 ml is equivalent to
restricting fluid 0.5 kg. increase in
intake weight due to fluid
retention in ESRD
 patient, therefore
limiting fluid is
necessary to avoid
fluid excess.
(Nursing Care Plans
pg. 852)

d. Instruct the patient d. Sodium intake

regarding the produces a feeling of
restricting dietary thirst. By restricting
sodium intake sodium intake, the
amount of fluid the
patient drinks can be
reduced
(Nursing Care Plans
pg. 852)
Dependent Nursing
Action:

a. Administer a.Diuretics enhances

diuretics (Furosemide) the excretion of both
to relieve excess fluid sodium and chloride in
volume as prescribed the urine so that water
by the physician follows and also
excreted thus fluid
overload is prevented
(Nursing Care Plans
pg. 852)

b. Encouraged b. This maintains fluid

compliance to Balance by osmosis
Dialysis Treatment and eliminates excess
as indicated fluid and waste
products in the
kidney
(Nursing Care Plans pg.
852)
Assessment Nursing Diagnosis Scientific Planning Intervention Rationale Evaluation
Explanation

Acute Pain related Acute Pain is

to blood flow present due to
blockage in veins edema in the
secondary to venous wall
possible DVT caused by clot
that impairs blood
flow that causes
pressure to the
inflamed vein
Assessment Nursing Diagnosis Scientific Planning Intervention Rationale Evaluation
Explanation

Impaired Urinary Goal:

Elimination After 3 days of
related to nursing intervention
decreased the client will
nephron experience weight
functioning gain less than 2-3
pounds on each day.

Short Term Goal:

After Nursing
Intervention the
client will be able to: INDEPENDENT NURSING
ACTIONS:
3. Verbalize 3. Discuss the following
understanding of the management needed to
management assesses increasing fluid
needed to assess volume:
increasing fluid e. Vital Sign assessment e. Signs of fluid excess
volume. (BP,RR,PR,TEMP) are elevated BP,
tachycardia, and
tachypnea. Elevated BP
is caused by sodium
retention and increased
intracellular fluid
volume
(Nursing Care Plans,
pg.852)

f. Assessment for other f.

signs of fluid volume
overload; edema,
weight gain,
distended neck vein,
orthopnea
 g. Excess fluid and
sodium intake can lead
to fluid volume excess in
g. Assess for patient’s the ESRD patient
compliance with (Nursing Care Plans pg.
dietary and fluid 852)
restrictions

h. Assess weight at h. To assess the

every visit before effectiveness of
and after dialysis treatment and
(weight gain not to monitoring of fluid
exceed 2 to 3 volume retention
pounds) (Nursing Care Plans pg.
852)

4. Discuss the
following measures to
prevent and lessen
fluid volume excess e.This maintains
optimal positioning for
air exchange
e. Have patient sit up
(Nursing Care Plans pg.
if she complains of
shortness of 852)
breath
f. This prevent and
lessen fluid
f. Advise patient to
accumulation in
elevate feet when
lower extremities
sitting down
(Nursing Care Plans pg.
 852)
4. Verbalize
understanding of g. Intake of fluid up to
the measures to 500 ml is equivalent to
prevent and lessen 0.5 kg. increase in
fluid volume excess weight due to fluid
g. Instruct the patient retention in ESRD
regarding patient, therefore
restricting fluid limiting fluid is
intake necessary to avoid
fluid excess.
(Nursing Care Plans pg.
852)

h. Sodium intake
produces a feeling of
h. Instruct the patient thirst. By restricting
regarding the sodium intake, the
restricting dietary amount of fluid the
sodium intake patient drinks can be
reduced
(Nursing Care Plans pg.
852)

Dependent Nursing
Action:

c. Administer c. Diuretics enhances

diuretics (Furosemide) the excretion of both
to relieve excess fluid sodium and chloride in
volume as prescribed the urine so that water
by the physician follows and also
excreted thus fluid
overload is prevented
(Nursing Care Plans pg.
852)
d. Encouraged
compliance to
Dialysis Treatment d. This maintains fluid
as indicated Balance by osmosis
and eliminates excess
fluid and waste
products in the
kidney
(Nursing Care Plans pg.
852)