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The patient presents with edema, weakness, and fatigue. Laboratory findings and vital signs are normal except for elevated blood pressure. The nurse assesses the patient's fluid intake and output daily and administers diuretics and antihypertensives as needed to manage fluid volume excess caused by compromised renal regulatory functions resulting in renal failure. The goal is for the patient to display appropriate urinary output and be free of edema after nursing interventions over 8 hours.
The patient presents with edema, weakness, and fatigue. Laboratory findings and vital signs are normal except for elevated blood pressure. The nurse assesses the patient's fluid intake and output daily and administers diuretics and antihypertensives as needed to manage fluid volume excess caused by compromised renal regulatory functions resulting in renal failure. The goal is for the patient to display appropriate urinary output and be free of edema after nursing interventions over 8 hours.
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The patient presents with edema, weakness, and fatigue. Laboratory findings and vital signs are normal except for elevated blood pressure. The nurse assesses the patient's fluid intake and output daily and administers diuretics and antihypertensives as needed to manage fluid volume excess caused by compromised renal regulatory functions resulting in renal failure. The goal is for the patient to display appropriate urinary output and be free of edema after nursing interventions over 8 hours.
Copyright:
Attribution Non-Commercial (BY-NC)
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Scarica in formato DOC, PDF, TXT o leggi online su Scribd
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 • Daily body weight, vital OBJECTIVE: normal; stable same time of day, on weight is best signs within weight, vital same scale, with monitor of fluid patient’s • Venous Decrease signs within same equipment and status normal range; distension urinary output patient’s normal clothing and absence of • Generaliz range; and edema. ed edema absence of • Assess skin, • Patient Water retention edema. face, dependent • Edema occurs reports of areas for edema primarily in Fatigue, dependent tissues weakness, Fluid volumes of the body, e.g., and malaise excess hands, feet, • V/S taken lumbosacral area. as follows Patient can gain up to 10 lb (4.5 kg) of T: 35˚C fluid before pitting P: 50 edema is detected R: 13 • Plan oral fluid BP: 130/90 replacement with • Helps avoid patient, within periods without multiple restrictions fluids, minimizes boredom of limited choices, and reduces sense of Kong, Michael Robert NCP
Collaborative deprivation and
thirst • Administer/restric t fluids as indicated. • Fluid management is usually calculated to replace output from all sources plus • Administer estimated insensible medication as losses indicated Diuretics, e.g., • Given early in furosemide (Lasix), oliguric phase of mannitol (Osmitrol) Renal Failure in an effort to convert to nonoliguric phase, flush the tubular lumen of debris, reduce hyperkalemia, and • Antihypertensive promote adequate s, e.g., clonidine urine volume. (Catapres) • May be given to treat hypertension by counteracting effects of decreased renal blood flow and/or circulating volume overload