In: Nursing
Write and submite a nursing care plan;
1) one from any of the renal diagnosis
1Chronic Renal Failure
Nursing Diagnosis:Excess fluid volume related to decreased urinary output,dietary excess and retention of sodium and water.
Goal:Maintenance of ideal body weight without excess fluid.
NURSING INTERVENTIONS | RATIONALE | EXPECTED OUTCOMES |
1Assess fluid status a Daily weight. b Intake and output balance. c Skin turgor and presence of edema, d Distention of neck veins. e Blood pressure ,pulse rate,and rythm fRespiratory rate and effort. |
1 Assessment provides bSaseline and ongoing database for monitoring changes and evaluating interventions. |
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2 Limit fluid intake to prescribed volume. | 2 Fluid restriction will be determined on basis of weight,urine output and response to therapy. | |
3 Identify potential sources of fluid. a Medications andfluids used to take or administer medications. b Foods. |
3 Unrecognized sources of excess fluids maybe identified. | |
4 Explain to patient and family rationale for fluid restriction. | 4 Understanding promotes patient and family cooperation with fluid restriction | |
5 Assist patient to cope with the discomforts resulting from fluid restriction. | 5 Increasing patient comfort promotes compliance with dietary restrictions. | |
6 Provide or Encourage frequent oral hygiene | 6 Oral hygiene minimizes dryness of oral mucous membranes. |