Medical Surgical Nursing

Plan of Nursing Care the Patient with Chronic Renal Failure

Nursing Diagnosis: Excess fluid volume related to decreased urine output, dietary excesses, and
retention of sodium and water
Goal: Maintenance of ideal body weight without excess fluid
Nursing Interventions Rationale Expected Outcomes

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. Limit fluid intake to prescribed
   volume.


3. Identify potential sources of
   fluid:
   a. Medications and fluids
   used to take or administer
   medications: oral and
   intravenous
   b. Foods


4. Explain to patient and family
   rationale for fluid restriction.


5. Assist patient to cope with the
   discomforts resulting from fluid
   restriction.


6. Provide or encourage frequent
   oral hygiene.

1. Assessment provides

baseline and ongoing

database for monitoring

changes and evaluating

interventions.

2. Fluid restriction will be

determined on basis of

weight, urine output,

and response to therapy.

3. Unrecognized sources of

excess fluids may be

identified.

4. Understanding promotes

patient and family

cooperation with fluid

restriction.

5. Increasing patient comfort

promotes compliance

with dietary restrictions.

6. Oral hygiene minimizes

dryness of oral mucous

membranes.

 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

Nursing Diagnosis: Imbalanced nutrition; less than body requirements related to anorexia, nausea,
vomiting, dietary restrictions, and altered oral mucous membranes
Goal: Maintenance of adequate nutritional intake

1. Assess nutritional status:
   a. Weight changes
   b. Laboratory values (serum
   electrolyte, BUN,
   creatinine, protein,
   transferrin, and iron
   levels)


2. Assess patient's nutritional
   dietary patterns:
   a. Diet history
   b. Food preferences
   c. Calorie counts


3. Assess for factors contributing to
   altered nutritional intake:
   a. Anorexia, nausea, or

1. Baseline data allow for

monitoring of changes

and evaluating

effectiveness of

interventions.

2. Past and present dietary

patterns are considered

in planning meals.

3. Information about other

factors that may be

altered or eliminated to

promote adequate

dietary intake is

provided.

4. Increased dietary intake

 Consumes protein

of high biologic

value

 Chooses foods

within dietary

restrictions that are

appealing

 Consumes high-

calorie foods

within dietary

restrictions

 Explains in own

words rationale for

dietary restrictions

and relationship to