- Excess Fluid Volume related to Kidney dysfunction, decreased urine output and Sodium retention as evidenced by Pulmonary congestion and Jugular vein distension
- Imbalanced Nutrition less than body Requirements related to Malabsorption and Food aversion as evidenced by Weight loss and Poor appetite
- Impaired Urinary Elimination related to chronic kidney disease as evidenced by Oliguria and Urinary retention
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: -Difficulty breathing -Anxiety -Weight gain or swelling Objective data: -Shortness of breath (orthopnoea, dyspnoea, increased respiratory rate) -Adventitious breath sounds (rales or crackles) -Abnormal electrolyte levels -High blood pressure -Decreased haemoglobin or haematocrit -Increased central venous pressure -Jugular vein distention -Oliguria -Tachycardia -Pulmonary congestion/edema | Excess Fluid Volume related to Kidney dysfunction, decreased urine output and Sodium retention as evidenced by Pulmonary congestion and Jugular vein distension | Patient will remain free of edema and maintain clear lung sounds without evidence of dyspnea. Patient will maintain balanced intake and output. | 1. Monitor the patient’s weight daily. It is estimated that 1 kg (2.2 lbs) of weight gained is equivalent to 1 liter of fluid retained. Monitoring the patient’s weight daily must be performed using the same scale during the same time of the day while the patient is wearing the same type of clothing for accurate results. 2. Restrict fluids as indicated. When restricting fluid intake in patients with CFR, all forms of fluid intake must be considered including oral, intravenous, and enteral sources. Fluid restriction is indicated to prevent and reduce fluid overload. 3. Administer medications as indicated. Diuretics are often prescribed to patients with CRF to increase urinary elimination of fluids and reduce retention and further complications. 4. Provide care to edematous extremities as needed. Patients with CRF often exhibit lower extremity edema or anasarca due to excess fluid retention. Reposition the patient every two hours to prevent the development of pressure ulcers and elevate affected extremities to improve blood flow and reduce swelling. 5. Prepare the patient for dialysis as indicated. Patients with stage 5 renal failure will require dialysis. Dialysis nurses are trained to provide hemodialysis or peritoneal dialysis. | Patient remained free of edema and maintain clear lung sounds without evidence of dyspnea. Patient maintained balanced intake and output. |
| Subjective data: Verbalizes unable to eat food Objective data: -Poor appetite -Malabsorption -Food aversion -Weight Loss | Imbalanced Nutrition less than body Requirements related to Malabsorption and Food aversion as evidenced by Weight loss and Poor appetite | Patient will report an adequate appetite level. Patient will demonstrate electrolytes and protein levels within acceptable limits. | 1. Encourage the patient to avoid foods high in potassium, sodium, and phosphorus. As CKD worsens, nutritional needs change. Avoiding foods high in potassium, sodium, and phosphorus can control hypertension, protect the heart, and prevent weakened bones. 2. Encourage the patient to eat the right amount and type of protein. A low-protein diet is often indicated for patients with CKD. Excessive protein can make the kidneys work harder in filtering waste products. Patients not receiving dialysis should consume 0.6-0.8g/kg of protein per day, while patients on dialysis can consume 1 -1.2g/kg per day. 3. Instruct the patient to limit alcohol intake. Drinking too much alcohol places additional strain on the kidney’s filtering function and accelerates the progression of CKD. 4. Instruct the patient to limit intake of saturated and trans-fat. Limiting saturated and trans-fat intake can lower fat buildup in the blood vessels, heart, and kidneys. Monounsaturated and polyunsaturated fats found in olive, avocado, and flaxseed oil are healthier alternatives to trans and saturated fats. 5. Increase fiber. Constipation is a common complaint with CKD. 20-25 g of fiber for women and 30-38 g for men is recommended to prevent constipation and maintain a balance of healthy bacteria in the gut. 6. Refer the patient to a renal dietitian. A renal dietician can recommend a specialized diet for patients with CKD, ensuring careful consideration of the patient’s nutritional status, fluid needs, and kidney health. | Patient reported adequate appetite level. Patient demonstrated electrolytes and protein levels within acceptable limits. |
| Subjective data: -Urgency -Hesitancy -Dysuria -Nocturia Objective data: -Bladder distention -Retention as detected through bladder scanning -Incontinence -Use of catheterization -Frequency | Impaired Urinary Elimination related to chronic kidney disease as evidenced by Oliguria and Urinary retention | Patient will produce at least 400 mL of urine per 24 hours. Patient will not experience complications from oliguria. | 1. Administer diuretics as indicated. Diuretics promote urinary elimination and prevent fluid overload in patients with CRF. 2. Administer fluids with caution. Fluid therapy can help with promoting urinary elimination but can cause worsening fluid retention and electrolyte imbalances. Monitor closely. 3. Educate on expectations. With CRF, urine production may increase and decrease. Educate the patient that as the disease progresses urine production will slow and may stop completely. 4. Prevent infections. Patients who are receiving dialysis due to severe CFR are at risk for infections from dialysis catheters and fistulas. Monitor for fever and abdominal pain. | Patient produced optimal urine output up to his producing capacity per 24 hours. Patient not experienced complications from oliguria. |