Question

Part 1.
Write a Reflection Paper about "Fluid Imbalances".

Part 2.
Make plan of care or interventions to address the following possible nursing diagnoses associated with AKI and ESRD.

a. Fluid volume excess
b. Decreased cardiac output
c. Impaired tissue integrity: renal

Answer 1

Questions 1

Question 2

A)

1. Assess 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 rhythm

f . Respiratory rate and effort

2. Limit fluid intake to prescribed volume

3. Identify potential sources of fluid :

a . Medications and fluids used to take or administer medications : oral and IV

b . Foods

4. Explain to patient and family the rationale for fluid restriction

5. Assist patient to cope with the discomforts resulting from fluid restriction

6. Provide or encourage frequent oral hygiene .

B)

>Monitor BP and HR

> Observe ECG or telemetry for changes in rhythm.

> Ascultate heart sound

> Assess color of skin, mucous membranes and nail beds. Note capillary refill time.

> Note occurrence of slow pulse, hypotension, flushing, nausea and vomiting, and depressed level of consciousness.

> Monitor for GI bleeding by guaiac testing all stools for blood.

>Investigate reports of muscle cramps, numbness of fingers, with muscle twitching, hyperreflexia.  

>Maintain bed rest or encourage adequate rest and provide assistance with care and desired activities.

C)

> Inspect skin for changes in color , turgor , vascularity . Note redness , excoriation . Observe for ecchymosis , purpura .

> Monitor fluid intake and hydration of skin and mucous membranes .

> Inspect dependent areas for edema . Elevate legs as indicated .

> Change position frequently; move patient carefully; pad bony prominences with sheepskin, elbow or heel protectors.  

> Provide soothing skin care. Restrict use of soaps. Apply ointments or creams (lanolin, Aquaphor).

> Keep linens dry, wrinkle - free.

> Investigate reports of itching

> Recommend patient use cool , moist compresses to apply pressure ( rather than scratch ) pruritic areas . Keep fingernails short ; encourage use of gloves during sleep if needed .

>Suggest wearing loose - fitting cotton garments .

> Provide foam or flotation mattress .