NCP

Excess fluid volume r/t stasis of fluid in the body

Cues Nursing

diagnosis

Scientific

explanation

Planning Interventions Rationale Expected

outcome

S>

O: the patient

manifest the

following:

Edema on

upper

extremities,

face and

neck

Oliguria

Hematuria

Rales

Hgb: 78

Excess fluid

volume r/t stasis

of fluid in the

body

Acute kidney

injury formerly

known as acute

renal failure is

the abrupt loss

of kidney

function

resulting to

sudden falls

down of the

glomerular

filtration rate. A

damage of

which

may cause

failure of the

Short term:

After 4hrs of

nursing

intervention the

pt. will

demonstrate

behaviours to

monitor fluid

status and

reduce

recurrence of

fluid volume

excess.

Establish

rapport and

assess general

condition.

Note presence

of medical

conditions or

situations that

potentiate fluid

excess.

Auscultate

breath sounds

To gain

trust and

establish

baseline

data

To assess

causative or

precipitating

factors

To note

presence of

Short term:

the patient shall

have

demonstrated

behaviours to

monitor fluid

status and

reduced

recurrence of

fluid volume

excess.

Long term:

Hct: 0.25

Ph: 6.6

SG: 1.025

BP: 160/80

The patient may manifest the following:

Jugular vein distention

Positive hepatojugular reflex

kidneys to filter

large molecules.

including those

with larger

molecule can

pass through the

GFR thus

leading to

proteinuria,

There is excess

fluid volume

because of

decreased levels

of protein

specifically

albumin which

regulates

oncotic

pressure. With

low levels, fluid

is retained and

not excreted.

Long term:

After 3-4 days of

nursing

intervention the

patient will have

stabilize fluid

volume as

evidence by

balance in intake

and output, VS

within pt’s

normal limits,

stable weight

and free of signs

of edema.

Advice to

restrict sodium

and fluid intake,

as indicated.

Record I/O

accurately.

Assess

neuromuscular

reflexes

Weigh daily or

on a regular

fluid

congestion

To prevent

more

retention of

fluids

.

To know the

gains and

losses of

fluids in the

body.

To evaluate

for

presence of

electrolyte

imbalances

To note the

The patient

shall have

stabilized fluid

volume as

evidence by

balanced I/O,

VS within

normal limits,

stable weight

and free of

signs of edema.

schedule, as

indicated.

Stress need for

mobility and

frequent

position

changes

Suggest

interventions,

such as

frequent oral

care, chewing

gum/hard

candy, use of

lip balm

changes in

weight.

To prevent

stasis and

reduce risk

of tissue

injury

.

To reduce

discomfort

of fluid

restrictions

Administer

medications

To

decrease

level of fluid

volume

excess

Ineffective renal tissue perfusion r/t impaired renal function

Cues Nursing

diagnosis

Scientific

explanation

Planning Interventions Rationale Expected

outcome

S>O

O:the patient

manifest the

following:

Edema on

upper

extremities,

face and neck

Oliguria

Hematuria

Hct: 0.25

Ph: 6.6

SG: 1.025

Albumin 3+

Ineffective renal

tissue perfusion

r/t impaired

renal function

One of the risk

factor of patient

having acute

kidney injury is

diabetes mellitus.

Wherein the

patient has type

2 diabetes

mellitus it occurs

when the

pancreas

produces

insufficient

amounts of the

hormone insulin

and/or the body’s

tissues become

resistant to

normal or even

Short term:

After 4 of NI, the

patient will

demonstrate

behaviours/

lifestyle changes

to improve

circulation.

Establish

rapport and

assess general

condition

Determine

factors related

to individual

situation

Note customary

baseline data

Determine usual

voiding pattern

To gain trust

and establish

baseline data

To assess

causative or

contributing

factors

To provide

comparison

with current

findings.

To know

presence of

oliguria or

Short term:

the patient shall

have

demonstrated

behaviours/

lifestyle

changes to

improve

circulation.

The patient may

manifest:

Urinary frequency or hesitancy

anuria

high levels of

insulin. This

causes high

blood glucose

(sugar) levels

leading to blood

viscosity causing

decrease renal

blood flow which

may result to

impaired function

of the kidneys

causing improper

tissue perfusion.

There is impaired

filtration and

circulation which

also causes a

problem with

other body

systems and

processes like

Long term:

After 3-4 days of

NI, the patient will

demonstrate

increased

perfusion as

individually

appropriate.

Review

laboratory

studies

Note mentation

Assess BP,

ascertain

patient’s usual

polyuria

To know if

there are

abnormalities

in the results

To know if

there’s an

alteration

brought about

by increased

creatinine or

deacrease

renal

perfussion

To determine

degree of

renal

Long term:

the patient shall

have

demonstrated

increased

perfusion as

individually

appropriate.

oxygen transport

in the blood and

the like.

range

Observe for

dependent or

generalized

edema

Administer

medications as

ordered

impairment

To evaluate

severity of the

disease

condition.

To treat

underlying

condition

Impaired urinary elimination r/t glumerular malfiltration

Cues Nursing

diagnosis

Scientific

explanation

Planning Interventions Rationale Expected

outcome

S>

O: the patient

manifest the

following:

Edema on upper

extremities, face

and neck

Oliguria

Hematuria

Hct: 0.25

Ph: 6.6

SG: 1.025

Albumin 3+

Impaired

urinary

elimination r/t

glumerular

malfiltration

There is

exceed fluid

volume

because of

decreased

levels of

protein

specifically

albumin which

regulates

oncotic

pressure. With

low levels, fluid

is retained and

not excreted.

Loss of kidney

functions and

as GFR

Short term:

After 4 hours of

nursing intervention

the patient will be

able to verbalize

understanding of

the condition.

Long term:

After 3-4 days of

nursing intervention

the patient will be

able to participate

in measures to

correct/compensat

e for defects.

Established

rapport

Monitor and

record Vital

signs

Assess

patient’s

general

condition

Review for

To gain trust

and

cooperation

of the

patient and

significant

others

To obtain

baseline

data

To know

what

problem and

interventions

Short term:

the patient

shall have

verbalize

understanding

of the condition

Long Term:

the patient

shall have

participated in

measures to

correct/

compensate

for defects.

The patient may

manifest:

Urinary

frequency/hesita

ncy

anuria

decreases, the

kidney cannot

excrete

nitrogenous

product and

causing

impairment in

the urinary

elimination and

together with

prolonged

usage of

medications

can lead to

further kidney

destruction

which may

further

decrease the

GFR and

destroys the

remaining

lab test

changes in

renal function

Establish

realistic

activity/goal

with the

patient

Determine

patient’s

pattern of

elimination

Determine

patient usual

fluid intake

Note

to prioritize

To assess

for causative

and

contributing

factors

Enhance

commitment

s to

promoting

optimal

outcomes

To assess

degree of

interference

To help

determine

level of

nephrons. This

will result to

inability of the

kidney to

concentrate

urine which

makes the

patient to have

a diagnosis of

impaired

urinary

elimination

condition of

skin and

mucous

membranes

and color of

urine

Emphasize

the need to

adhere with

the

prescribed

diet

Emphasize

importance of

having good

hygiene

Emphasize

importance of

adhering to

hydration

To assess

level of

hydration

To prevent

aggravation

of disease

condition

To prevent

spread of

infection

To promote

treatment

regimen

wellness

Impaired skin integrity r/t facial edema and changes in skin pigmentation

Cues Nursing Scientific Planning interventions Rationale Expected

diagnosis explanation outcome

S>O

O:The patient

manifests the

following:

Rough and

dry skin

Pruritus on

upper and

lower

extremities

and on

abdomen

Edema on

the face,

neck and

upper

extremities

impaired skin

integrity r/t

facial edema

and changes in

skin

pigmentation

Because of the

complication of

the underlying

disease

condition which

may result with

the impairment

of the function of

the kidneys thus

leading to

edema With this

condition, the

skin is stretched

abnormally

because of fluid

retention. If the

fluid will not be

excreted, there

is a possibility of

impairment in

Short term:

After 4 of NI,

the patient will

identify

individual risk

factors that may

contribute to the

disease

condition.

Long term:

After 2-3 days of

NI, the patient

will demonstrate

behaviours/

Techniques to

prevent skin

Establish

rapport

Assess

general

condition

Assess skin

condition

Note

presence of

conditions/

situations that

may impair

skin integrity.

Monitor

weight daily

To gain trust and

cooperation

Establish

baseline data

To reveal

abnormality/

skin disruption

To know

causative/

Contributing

factors.

To monitor

presence of

Short term:

the patient shall

have identified

individual risk

factors that may

contribute to the

disease condition

Long term:

the patient shall

have

demonstrated

behaviours/

Techniques to

prevent skin

breakdown.

The patient may

manifest:

Pain

Numbness on

the area

affected

Impaired

circulation

Impaired

pigmentation

skin integrity. breakdown. as indicated

Provide

meticulous

skin care

Frequently

change

patient’s

position

Emphasize

importance of

adequate

nutrition

Encourage

exercise

edema.

To prevent skin

breakdown

To promote

proper circulation

and prevent

excessive

pressure on the

skin

To maintain

general good

health and skin

turgor.

To enhance

circulation

Suggest use

of lotions

Administer

diuretics as

ordered

To decrease

irritable itching

To decrease

edema

Risk for injury r/t abnormal blood profile secondary to disease condition

Cues Nursing Scientific Planning interventions Rationale Expected

diagnosis explanation outcome

S=O

O: The patient

manifested

decreased in

haemoglobin

pale

palpebral

conjunctiva

pale nail

beds

hgb count of

78

the patient may

manifest:

physical

Risk for

injury r/t

abnormal

blood profile

secondary to

disease

condition.

The damage or

inflammation due

to the

complication of

the disease

condition which

compresses renal

artery therefore

decreasing blood

supply to the

kidney which

suppresses or

alters it’s function,

one of the

kidney’s function

is to produce

erythropoetin

which is

responsible for

SHORT TERM:

After 3 hours of

nursing

intervention the

patient will

verbalize

understanding

of individual

factors that

contribute to

possibility of

injury.

LONG TERM:

After 2-3 days of

nursing

interventions,

the patient will

Monitor vital

signs

assess factors

or signs of

fatigue

Note reports of

increasing

fatigue or

weakness

Elevate

HOB/position

client

appropriately

To provide a

baseline data

for future

comparison

To provide

appropriate

interventions

May reflect

effects of

anemia and

cardiac

responses.

To maintain

airway

SHORT TERM:

The pt’s shall have

verbalized

understanding of

individual factors

that contribute to

possibility of injury.

LONG TERM:

The patient shall

have demonstrated

behaviors, lifestyle

changes to reduce

risk factors and

protect self from

injury and

improvement in

injury

bruises

sensory

dysfunction

the oxygen

carrying

component of the

blood, an

alteration in this

function

decreases

oxygen supply to

the body causing

anemia, which

causes fatigue

and making the

patient at risk for

injury.

demonstrate

behaviors,

lifestyle

changes to

reduce risk

factors and

protect self from

injury and

improvement in

laboratory

values.

Encourage

frequent

change in

position and

deep-breathing

Provide

adequate rest

and limit

activities to

within clients

tolerance

Promote safety

measure

Provide oxygen

supplement as

prescribed

Promotes

optimal chest

expantion

To limit

consumption a

demand of

oxygen

To prevent

injury and blood

loss

To increase

oxygen supply

in the body

laboratory values.

Administer meds

as prescribed

To treat

underlying

conditions that

may aggravate

the condition.

Ineffective Airway clearance related to retained secretions in the trachea-bronchial tree AEB rales upon auscultation

CuesNursing

diagnosis

Scientific

explanationplanning interventions rationale

Expected

outcome

S>O

O :pt manifest

the following

rales

changes in

rate, depth

of

respiration

s

pale

palpebral

conjuntiva

pale lips

nasal

secretions

productive

Ineffective

Airway

clearance

related to

retained

secretions

in the

trachea-

bronchial

tree AEB

rales upon

auscultation

The patient

develop

pulmonary

congestion due to

retention of fluid

in the body, in

diabetes mellitus

fluid retention

happen because

with the

abscence of

glucose, the body

will then

metabolize

protein in

replacement of

glucose that can’t

be metabolize for

Short Term:

After 4 hours of

nurse-patient

interaction, the

patient’s will

demonstrate

ways in

improving

airway patency.

Long Term:

After 1 week of

NPI, pt will

maintain airway

Monitor and

record vital

signs

Assess

rate/depth of

respirations and

chest

movement.

Monitor for

signs of

respiratory

failure (e.g.

cyanosis and

severe

tachypnea)

To obtain

baseline data

Tachypnea,

shallow resp., and

asymmetric chest

movement are

frequently present

because of

discomfort of

moving chest

and/or fluid in

lung.

Decreased airflow

occurs in areas

Short Term:

The patient

shall have

demonstrated

ways in

improving

airway

patency

Long Term:

The patient

shall have

maintained

cough

the pt. may

manifests:

rapid and

shallow

breathing

cyanosis

DOB

SOB

retractions

energy

production

leading to protein

wasting resulting

to decrease

colloid-oncotic

pulling force in

the intravascular

spaces. Thus,

more fluid stays

in the third space

resulting to

edema. This

edema may occur

at any part of the

body like the

lungs. This may

lead to pulmonary

congestion. The

body is unable to

clear the airway

due to secretions.

patency.

Auscultate lung

fields, noting

areas of

decreased/abse

nt airflow and

adventitious

breath sounds

(e.g. crakles,

wheezes)

Elevate head of

bed, change

position

frequently

consolidated with

fluid.

keeping head

elevated lowers

diaphragm,

promoting chest

expansion,

aeration of lung

segments, and

mobilization and

expectoration of

secretions to keep

airway clear.

Deep breathing

facilitates

airway

patency

This fluid in the

lungs may affect

the oxygen and

carbon dioxide

diffusion in the

alveoli. The

function of the

alveolar-capillary

membrane

becomes altered

resulting to an

impairment in the

exchange of

gases, which are

oxygen and

carbon dioxide

Assist client

with frequent

deep-breathing

exercises.

Demonstrate

chest and

effective

coughing while

in upright

position

Suction if

indicated

Assist

with/monitor

effects of

nebulizer

maximum

expansion of

lungs/smaller

airways.

stimulates cough

or mechanically

clears airways

facilitates

liquefaction and

removal of

secretions

treatments and

other

respiratory

physio-therapy.

Perform

treatments

between meals

and limit fluids

when

appropriate

Administer

medications as

indicated

Aids in the

reduction of

bronchospasm

and mobilization

of secretions.