1.
Medical Diagnosis: Renal Failure
Problem: Fluid Volume Excess RT Decreased Glomerular Filtration Rate and Sodium Retention
Assessment Nursing Diagnosis Scientific
Explanation
Planning Interventions Rationale Evaluation
Subjective: (none)
Objective:
Patient manifested:
 Edema
 Hypertension
 Weight gain
 Pulmonary
congestion (SOB,
DOB)
 Oliguria
 Distended jugular
vein
 Changes in
mental status
Patient may
manifest:
Fluid Volume Excess
R/T decrease
Glomerular filtration
Rate and sodium
retention
Renal disorder
impairs glomerular
filtration that
resulted to fluid
overload. With fluid
volume excess,
hydrostatic pressure
is higher than the
usual pushing excess
fluids into the
interstitial spaces.
Since fluids are not
reabsorbed at the
venous end, fluid
volume overloads the
lymph system and
stays in the
interstitial spaces
leading the patient to
have edema, weight
gain, pulmonary
congestion and HPN
at the same time due
to decrease GFR,
nephron
hyperthrophized
leading to decrease
ability of the kidney
to concentrate urine
and impaired
excretion of fluid
thus leading to
Short Term:
After 4-8 hours of
nursing
interventions, patient
will demonstrate
behaviors to monitor
fluid status and
reduce recurrence of
fluid excess
Long Term:
After 3 days of
nursing intervention
the patient will
manifest stabilize
fluid volume AEB
balance I & O, normal
VS, stable weight,
and free from signs
of edema.
1. Establish rapport
2. Monitor and
record vital signs
3. Assess possible
risk factors
4. Monitor and
record vital signs.
5. Assess patient’s
appetite
6. Note
amount/rate of
fluid intake from
all sources
7. Compare current
weight gain with
admission or
previous stated
weight
1. To assess
precipitating and
causative factors.
2. To obtain
baseline data
3. To obtain
baseline data
4. To note for
presence of
nausea and
vomiting
5. To prevent fluid
overload and
monitor intake
and output
6. To monitor fluid
retention and
evaluate degree
of excess
7. For presence of
crackles or
congestion
Short Term:
The patient shall
have demonstrated
behaviors to monitor
fluid status and
reduce recurrence of
fluid excess
Long Term:
The patient shall
have manifested
stabilized fluid
volume AEB balance I
& O, normal VS,
stable weight, and
free from signs of
edema.

2.
oliguria/anuria. 8. Auscultate
breath sounds
9. Record
occurrence of
dyspnea
10. Note presence of
edema.
11. Measure
abdominal girth
for changes.
12. Evaluate
mentation for
confusion and
personality
changes.
13. Observe skin
mucous
membrane.
14. Change position
of client timely.
15. Review lab data
like BUN,
Creatinine,
Serum
electrolyte.
16. Restrict sodium
and fluid intake if
8. To evaluate
degree of excess
9. To determine
fluid retention
10. May indicate
increase in fluid
retention
11. May indicate
cerebral edema.
12. To evaluate
degree of fluid
excess.
13. To prevent
pressure ulcers.
14. To monitor fluid
and electrolyte
imbalances
15. To lessen fluid
retention and
overload.
16. To monitor
kidney function

3.
indicated
17. Record I&O
accurately and
calculate fluid
volume balance
18. Weigh client
19. Encourage quiet,
restful
atmosphere.
20. Promote overall
health measure.
and fluid
retention.
17. Weight gain
indicates fluid
retention or
edema.
18. Weight gain may
indicate fluid
retention and
edema.
19. To conserve
energy and lower
tissue oxygen
demand.
20. To promote
wellness.