NURSING DIAGNOSIS OF RENAL FAILURE
- Impaired fluid volume excess related to decreased urine output as evidenced by swelling over the body parts
- Pain related to burning micturition
- Ineffective breathing pattern related to fluid over load as evidenced by increased breath rate
- Impaired nutrition less than body requirement related to dietary restriction as characterized by physical weakness
- Activity intolerance related to retention of waster products as evidenced by decreased ADL
- Impaired skin integrity related excessive fluid collection in the body as evidenced by swelling over the body parts
- Deficient knowledge regarding clinical condition and treatment
- Fear and anxiety related to diagnosis and alteration in urinary function
- Risk for infection depression of immunologic deficiencies as evidenced by infection file
- Risk for hyperkalemia related to electrolyte retention as evidenced by ECG changes
Impaired fluid volume excess related to decreased urine output as evidenced by swelling over the body parts
- Assess the fluid status of the client
- Daily weight monitoring
- Intake and output chart
- Presence of oedema
- Blood pressure and pulse rate
- Respiratory effort and rate
- Limit fluid intake to prescribed volume
- Identify the potential source of fluid
Pain related to burning micturition
- Assess the characteristic pain
- Provide comfortable position
- Check vital signs
- ECG monitoring at each episode pain
- Provide diversional therapy
- Administer oxygen therapy through nasal cannula
- Administer analgesics as prescribed
Ineffective breathing pattern related to fluid over load as evidenced by increased breath rate
- Assess the breathing pattern or the client
- Monitor the saturation
- Provide comfortable position
- Teach patient diaphragmatic and pursed lip breathing
- Administer loop diuretics
- Encourage alternating activity with rest periods
Imbalance nutrition less than body requirement related to dietary restriction as characterized by physical weakness
- Assess dietary pattern of the client
- Provide small and frequent diet
- Give client a list of permitted food or fluids and encourage involvement in menu choice
- Offer frequent mouth care
- Monitor laboratory studies
- Provide high-caloric, low or moderate protein diet
- Restrict potassium, sodium,intake as indicated
Impaired skin integrity related excessive fluid collection in the body as evidenced by swelling over the body parts
- Assess the skin conditions of the client
- Evaluate client’s skin care practices and hygienic issues
- Monitor the surface area of foot
- Monitor the uraemic status
- Determine the area at risk for injury
Fear and anxiety related to diagnosis and alteration in urinary function
- Assess level of fear and anxiety
- Acknowledge normalcy of feelings in this situation
- Provide opportunity for client to ask question and verbalize concerns
- Point out positive indicators of treatment
- Provide psychological support to the client and family members
Risk for hyperkalemia related to electrolyte retention as evidenced by ECG changes
Monitor the serum potassium level
Assess patient ECG changes
Monitor blood pressure
Monitor RBC count, hemoglobin , hematocrit level as indicated
Prepare the patient for cardiac ultrasound to aid in diagnose for pericardial effusion and cardiac tamponade
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