CUES EXPLANATION OF THE OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

PROBLEM
Subjective: In CKD, there is impaired Short term: DIAGNOSTICS:
fluid elimination. This >establish rapport with the >to gain trust and active
Nahihirapan akong causes the inability of the
After 4hours of Nursing pt. and significant others. participation.
umihi meron pero onti body to excrete excess
lang lumalabas water and waste products. Interventions, the pt. will
Nahihirapan din akong As a result, there is demonstrate improvement >determine the pathology >to identify causative or
huminga decrease in blood volume
in urine elimination. of bladder dysfunction. contributing factor.
and also a decrease
perfusion to the different
Objectives: parts of the body including >review lab. Test >to determine any changes
- edema on both lower the kidneys that will lead to
Long trem: in renal function and
extremities decrease urine output.
presence of infection.
- less than 30 ml of
urine per hour After 4 days of NI, the pt.
- skin is pale will have return of normal
- pale sclera voiding pattern and
>palpate bladder >to assess for urinary
-CBG: 135 elimination.
retention.

>investigate pain, noting >to assess degree of

location, duration and interference or disability.
Nursing Diagnosis: intensity, presence of
Impaired Urinary bladder spasm, back or
Elimination related to
flank pain.
decreased urine output
secondary to CKD
>determine pts usual daily >to help determine of
fluid intake. hydration.
>observe for signs of >pt. with urinary retention
infection, cloudy, foul odor, are at high risk for
and bloody urine developing infection.

>Accurately record intake > Decrease in output (to

and output (I&O) noting to less than 400 ml per 24

include hidden fluids hours) may indicate acute

such as IV antibiotic failure, especially in high-

additives, liquid risk patients. Accurate

medications, frozen treats, monitoring of I&O is

ice chips. Religiously necessary for determining

measure gastrointestinal renal function and fluid

losses and estimate replacement needs and

insensible losses reducing risk of fluid

(sweating), including overload. Do note that

wound drainage, hypervolemia usually

nasogastric outputs, occurs in anuric phase of

and diarrhea. ARF

> Daily body weight is

>Weigh daily at same
best monitor of fluid
time of day, on same
scale, with same status. A weight gain of

equipment and clothing. more than 0.5 kg/day

suggests fluid retention.

> >Edema occurs

>Assess skin, face,
primarily in dependent
dependent areas for
tissues of the body,
edema. Evaluate degree
(hands, feet, lumbosacral
of edema (on scale of +1
area). Patient can gain up
+4).
to 10 lb (4.5 kg) of fluid

before pitting edema is

detected. Periorbital

edema may be a

presenting sign of this

fluid shift because these

fragile tissues are easily

distended by even

minimal fluid

accumulation.

> Tachycardia and

>Monitor heart rate (HR), hypertension can occur
because of: (1) failure of
BP,
the kidneys to excrete
urine, (2) excess fluid
resuscitation during
efforts to treat
hypovolemia and/or
hypotension or convert
oliguric phase of renal
failure, (3) changes in the
renin-angiotensin system.

>Auscultate lung and

heart sounds. >Fluid overload may lead

to pulmonary edema and
HF evidenced by
development of
adventitious breath
sounds, extra heart
sounds.
>Assess level of

consciousness.
> May reflect fluid shifts,
Investigate changes in
accumulation of toxins,
mentation, presence of acidosis, electrolyte

restlessness. imbalances, or developing

hypoxia.
Monitor diagnostic
studies:
Blood urea
nitrogen (BUN),
creatinine (cr)

BUN assess management

of renal dysfunction. Both
values may increase but
creatinine is a better
indicator of renal function
because it is not affected
by hydration, diet, and
tissue catabolism. Dialysis
is usually indicated if ratio
is higher than 10:1 or if
Serum sodium.
therapy fails to indicate
fluid overload or metabolic
acidosis.

Hyponatremia may result

from fluid overload
(dilutional) or kidneys
inability to conserve
sodium. Hypernatremia
Serum
potassium. indicates total body water
 deficit.

Lack of renal excretion

and/or selective retention
Hb/Hct. of potassium to excrete
excess hydrogen ions
leads to hyperkalemia,
requiring prompt
intervention

Decreased values may

indicate hemodilution
(hypervolemia) however,
Serial chest x- during prolonged failure,
rays. anemia frequently
develops as a result of
RBC loss. Other possible
causes (active or occult
hemorrhage) should also
be evaluated..

Increased cardiac size,

THERAPEUTICS:
> Hook patient to an O2 prominent pulmonary
theraphy vascular markings, pleural
effusion, congestion
>Administer and/or indicate acute responses
restrict fluids as indicated. to fluid overload or chronic
changes associated with
renal and heart failure.

>for him to ease his

difficulty of breathing

>Fluid management is
usually calculated to
replace output from all
sources plus estimated
insensible losses
(metabolism, diaphoresis).
Prerenal failure
(azotemia) is treated with
volume replacement
and/or vasopressors. The
oliguric patient with
adequate circulating
volume or fluid overload
> Administer diuretics:
who is unresponsive to
furosemide
fluid restriction
and diuretics requires
dialysis. Note: During
 oliguric phase, push/pull
therapy (push IV fluids
and diurese with diuretics)
may be tried to stimulate
kidney function.

>Rapid-acting potent
sulfonamide loop
diuretic and
> Prepare for dialysis.
antihypertensive.
Inhibits reabsorption of
sodium and chloride
primarily in loop of Henle
and also in proximal and
distal renal tubules; an
antihypertensive that
decreases edema and
intravascular volume.

>Reduction of uremic
>Insert indwelling toxins and correction of
catheter, as indicated. electrolyte imbalances
and fluid overload may
limit and prevent cardiac
manifestations, including
hypertension and
pericardial effusion.

>Catheterization excludes
 lower tract obstruction and
provides means of
EDUCATIVE: accurate monitoring of
> tell patient to decrease urine output during acute
fluid intake phase; however,
indwelling catheterization
may be contraindicated
because of increased risk
of infection.

>advised to report if DOB

worsens >because the patient
cannot normally urinate
and there is a fluid
overload as manifested by
edema on both lower
extremities

> this ,aybe a sign of fluid

accumulation in the lungs