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In: Nursing

Write and submite a nursing care plan; 1) one from any of the renal diagnosis

Write and submite a nursing care plan;

1) one from any of the renal diagnosis

Solutions

Expert Solution

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.
  • Demonstrates no rapid weight changes.
  • Maintains dietary and fluid restrictions.
  • Exhibits normal skin turgor without edema.
  • Exhibits normal vital signs.
  • Exhibits no neck vein distention.
  • Reports no diffficulty breathing or shortness of breath.
  • Performs oral hygiene frequently.
  • Reports decreased thirst.
  • Reports decreased dryness of oral mucous membranes
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.

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