NURSING CARE PLAN FOR

PATIENT WITH EXCESSIVE FLUID

VOLUME RELATED TO CHRONIC
KIDNEY DISEASE
Tsaabitah Rizqilla Anwar, 1706039156
 Case
Mr. F age 56 years old was treated in the disease room on the 3rd day with a diagnosis of
CKD stage V. Currently the patient complains of shortness of breath again, after initiation
of HD in the ER. The assessment results showed BP: 150/90 mmHg, RR: 28x / min, Pulse: 96x
/ min, pitting edema + 3 in both lower extremities, conjunctival anemic (+).
• Lab examination results:
• Hb 7.9 gr / dl, hematocrit 23%, erythrocytes 3 million / µL.
• Ureum 202 mg / dl, Creatinine 8.1 mg / dl
• Na 131, Potassium 5.1, Chloride 99.
• AGD: Ph 7.29; PC02 25; HC03 14; P02 95; BE-11.1.
At present the patient is receiving Lasix IV medical therapy, and oral medicines: CaCo3,
As.Folat, Bicnat, Kalitake. Patients are planned to have regular HD 2x a week and start
tomorrow. The patient's wife tells you that Mr. F does not want regular dialysis, because
the family's main income comes from Mr. F's business. Patients also previously had a
history of type 2 diabetes and did not want to take medication from a doctor, only
wanted herbal medicine.
ASSESSMENT
 Subjective Data Objective Data Defining Characteristics

The patient complained of BP: 150/90 mmHg Alteration in blood pressure

shortness of breath again
RR: 28x/menit Alteration in respiratory pattern
Defining Characteristics: Dyspnea
Ereum 202 mg/dl, Creatinine 8,1
Azotemia
Mr F wants to avoid regular dialysis mg/dl
Hematocrit 23% Decrease in hematocrit

Mr.F. Patients also previously had Hb 7,9 gr/dl Decrease in hemoglobin

history of type 2 diabetes Pitting edema + 3 in both lower

Edema
extremities

Mr. F does not want to take Na 131

medicine from a doctor, only Kalium 5,1

wants herbal medicine Klorida 99 Electrolyte imbalance

AGD (Ph 7,29 ; PC02 25 ; HC03 14
; P02 95 ; BE -11,1)
 Additional Data
Adventitious breath sound Jugular vein distension
Alteration in mental status Oliguria
Alteration in pulmonary artery pressure (PAP) Orthopnea
Alteration in urine specific gravity Paroxysmal nocturnal dyspnea
Anasarca Pleural effusion
Anxiety Positive hepatojugular reflex
Hepatomegaly Presence of S3 heart sound
Increase in central venous pressure (CVP) Pulmonary congestion
Intake exceeds output Restlessness
Weight gain over short period of time
DIAGNOSIS

Excessive Fluid Volume

Definition:
 Surplus intake and/or retention of fluid (NANDA, 2018)
 State in which a client experiences or is at risk of experiencing
intracellular or interstitial fluid overload (Carpenito, 2010)
PLANNING
The client will understand the importance of prescribed (restricted) fluid amounts.
Demonstrates no rapid weight changes
Maintains dietary and fluid restrictions
Exhibits normal skin turgor without edema
Exhibits normal vital signs
Exhibits no neck vein distention
Reports no difficulty breathing or shortness of breath
Performs oral hygiene frequently
Reports decreased thirst
Reports decreased dryness of oral mucous membranes
INTERVENTION
Actions
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. Note presence of peripheral or sacral edema,
respiratory rates, dyspnea, orthopnea,
distended neck veins, and electrocardiogram
(ECG) changes indicative of ventricular
hypertrophy.
3. Limit fluid intake to prescribed volume.
Rational
1. Assessment provides baseline and ongoing
database for monitoring changes and
evaluating interventions.
2. Fluid volume excess due to inefficient dialysis or
repeated hypervolemia between dialysis
treatments may cause or exacerbate HF, as
indicated by signs and symptoms of respiratory
and systemic venous congestion.
3. Fluid restriction will be determined on basis of
weight, urine output, and response to therapy.
Actions
4. Identify potential sources of fluid:
a. Medications and fluids used to take or
administer medications: oral and
intravenous
b. Foods
5. Explain to patient and family rationale for fluid
restriction.
6. Assist patient to cope with the discomforts
resulting from fluid restriction.
7. Provide or encourage frequent oral hygiene.
8. Monitor laboratory reports for serum albumin
level and serum electrolyte levels.
Rational
4. Unrecognized sources of excess fluids may be
identified.
5. Understanding promotes patient and family
cooperation with fluid restriction.
6. Increasing patient comfort promotes
compliance with dietary restrictions.
7. Oral hygiene minimizes dryness of oral mucous
membranes.
8. Accurate assessments and I&O records ensure
proper adherence to the treatment regimen
and alerts the client to alterations in fluid
balance.
Bibliography
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