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Nursing Care Plan

Nursing Diagnosis: Deficient Fluid Volume related to hypovolemia
Long Term Goals: The patient will experience adequate renal perfusion as evidenced by urine output of at least 30 cc/hr

Outcome/ Short Term Patient-Centered Goals

Planning/Interventions

Rationale

Evaluation

The patient will exhibit signs of adequate perfusion:
    *normal MAP 70 or greater
    *urine output of 30 cc/hr
    *HR  60-100 bpm.  

Monitor HR, BP and hemodynamic parameters every hour.

Monitor daily weights.

Hemodynamic parameters reveal information about adequacy of fluid volume status.

*HR, BP and hemodynamics
      are within normal limits.

 

Assess for signs and symptoms of intravascular volume depletion if urine output decreases.  Consider common causes of decreased cardiac output.

Acute renal failure may be caused by decreased cardiac output related to hypovolemia, trauma, inadequate volume replacement, burns, heart failure, sepsis.

 

 

Promptly plan for administration of fluids to increase intravascular fluid volume.

Both crystalloids and colloids may be used to boost intravascular volume depending upon the cause of the fluid loss.  Normal saline fluid challenges may be used until the patient’s CVP reaches 12.

*Urine output increases following fluid replacement.
*HR, BP, CVP and urine output are WNL
*Moist mucous membranes.

 

Assess patient for signs and symptoms of fluid volume overload.

Fluid volume overload is a possibility anytime fluid replacement occurs.

*The patient will maintain normal hemodynamic parameters, clear breath sounds, normal respirations.

 

Administer norepinephrine to improve renal perfusion if fluid challenges do not improve MAP to 70 or greater.

Norepinephrine is now indicated to increase BP and MAP for patients with acute renal failure.

MAP = 70 or greater.

 

Consult a nephrologist if patient does not respond to volume resuscitation.

Studies have shown that patients who are referred to nephrology early have better outcomes.

 

 

Nursing Diagnosis: Excess Fluid Volume related to renal failure
Long Term Goals: The patient will experience normal fluid volume status as evidenced by balanced intake and output, weight loss, stable vital signs, normal breath sounds and no JVD.

Outcome/ Short Term Patient-Centered Goals

Planning/Interventions

Rationale

Evaluation

The patient will exhibit signs of optimal fluid volume status:
    *normal MAP (70-100)
    *lungs clear to auscultation
    *HR  60-100 bpm  
    *Intake approximately =
      output

Monitor HR, BP, hemodynamic pressures and urine output hourly.

 

Monitor daily weights and maintain accurate I & O.

Onset of tachycardia, increased work of breathing, onset of crackles, or elevated CVP or PA pressures can all provide signs of fluid volume excess.

Daily weights provide an accurate indicator of fluid volume status.  (1 lb = 500 mL).

HR 60-100 beats/min.
BP (MAP) = 70-100.
Lungs are clear to auscultation.
Neck veins are flat.
Respirations are regular and easy.
Intake = 500; Output = 450.

 

Assess for possible causes of fluid volume excess.

Intrinsic renal failure is commonly caused by prolonged prerenal failure or nephrotoxins.  Nephrotoxicity is a significant factor for patients who have pre-existing decreased renal function: diabetics, older adults and patients with decreased renal perfusion.

 

 

Avoid administration of drugs known to cause nephrotoxicity:
NSAIDS, aminoglycosides, cephalosporins, contrast media, ACE inhibitors.

For patients with diminished renal function, exposure to nephrotoxic agents can produce serious insult to the kidneys.

 

 

Restrict total fluid intake from all sources.

This will help to prevent worsening fluid volume excess.
Possibly would add previous day’s output plus insensible fluid loss for total 24 allowance.

 

 

Concentrate IV medication infusions.

To reduce total volume administered over 24 hrs.

 

 

Prepare for continuous renal replacement therapy if output does not improve.

Continuous renal replacement therapy provides a means by which fluid is removed in a very controlled manner to avoid hemodynamic compromise.  Renal replacement therapy is indicated when the patient develops any of the following during ongoing medical therapy:  oliguria with fluid overload, hyperkalemia, hyponatremia, severe acidemia, azotemia, mental changes, neuropathy, or pericarditis.

Fluid is removed at the desired hourly rate;
Patient remains hemodynamically stable.






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