- Acute Kidney Injury related to fluid overload, fluid shifts and electrolyte imbalance as evidenced by EKG changes, Jugular vein distention and decreased central venous pressure
- Deficient Fluid Volume related to kidney dysfunction and excessive fluid loss as evidenced by decreased blood pressure and decreased urine output
- Excess Fluid Volume related to Compromised regulatory mechanism, Excess fluid intake and Excess sodium intake as evidenced by oliguria, generalized edema and Dyspnea
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Verbalize difficulty to breathe Objective Data: -Dysrhythmias, -Decreased central venous pressure -Dyspnea -Prolonged capillary refill -Decreased peripheral pulses -Crackles in lungs -Cough | Acute Kidney Injury related to fluid overload, fluid shifts and electrolyte imbalance as evidenced by EKG changes, Jugular vein distention and dyspnea | Patient will show adequate cardiac output as evidenced by blood pressure, heart rate, and rhythm within normal limits. Patient will be able to return to baseline activity level. Patient will display adequate breathing as evidenced by appropriate oxygen saturation level and absence of adventitious breath sounds. Patient will be able to verbalize future self-care activities to improve cardiac health. | 1. Administer oxygen. High-flow oxygen or a ventilator may be necessary to increase oxygenation for cardiac function and tissue perfusion. 2. Encourage bed rest. Frequent rest is required to prevent overexertion and stress on the heart. Group activities and assessments to reduce interruptions and maximize sleep. 3. Monitor electrolytes. Increased and decreased levels of potassium can affect the heart muscle and cause arrhythmias. Calcium has cardiac effects, and decreased levels can enhance the toxic effects of potassium. 4. Administer medications as indicated. Inotropic agents may be prescribed to improve cardiac output though care must be taken to preserve renal function. Antidysrhythmic, vasopressors, and blood products may be required. Monitor administration closely to prevent fluid overload. | Patient shown adequate cardiac output as evidenced by blood pressure, heart rate, and rhythm within normal limits. Patient returned to baseline activity level. Patient displayed adequate breathing as evidenced by appropriate oxygen saturation level and absence of adventitious breath sounds. Patient verbalized future self-care activities to improve cardiac health. |
| Subjective Data: Verbalize that diminished Urine output Objective Data: -Hypotension -Tachycardia -Decreased urine output -Dry skin -Dry mucous membranes -Increased temperature -Thirst -Weakness | Deficient Fluid Volume related to Kidney dysfunction and excessive fluid loss as evidenced by decreased blood pressure and decreased urine output | Patient’s vital signs will remain stable and/or return to patient’s baseline. Patient’s intake and output will stabilize. Patient’s lab values will return to baseline. Patient will verbalize measures to take at home to maintain hydration/prevent dehydration. | 1. Administer intravenous fluid replacement as indicated. Fluid administration in AKI is indicated to help optimize circulating volume, increase cardiac output, promote perfusion pressure, and ultimately improve renal blood flow and function. Blood products may also be necessary if fluid volume deficit is caused by blood loss. 2. Encourage adequate fluid intake 24/7 as indicated. During the diuretic phase, AKI may progress to the oliguric phase if fluid intake is not maintained. Reversal and prevention of hypovolemia are vital in preventing further kidney damage. Provide fresh water and foods with high water content throughout the day. 3. Insert a urinary catheter as indicated. The placement of a urinary catheter allows for accurate measurement of urine output. Intensive monitoring of urine output is associated with improved outcomes in AKI. 4. Treat factors contributing to deficient fluid volume. If the patient is experiencing vomiting, diarrhea, and fever and is unable to tolerate PO intake, treat these symptoms to prevent further fluid loss. | Patient’s vital signs remained stable and/or return to patient’s baseline. Patient’s intake and output got stabilized. Patient’s lab values returned to baseline. Patient verbalized measures to take at home to maintain hydration/prevent dehydration. |
| Subjective Data: Difficulty breathing Anxiety Weight gain or swelling Objective Data: -Shortness of breath (orthopnea, dyspnea, increased respiratory rate) -Adventitious breath sounds (rales or crackles) -Abnormal electrolyte levels -High blood pressure -Edema -Increased central venous pressure -Jugular vein distention -Oliguria -Pulmonary congestion/edema | Excess Fluid Volume related to Compromised regulatory mechanism, Excess fluid intake and Excess sodium intake as evidenced by oliguria, generalized edema and Dyspnea | Patient will display normal fluid volume as evidenced by balanced intake and output. Patient will display no signs of edema or sudden weight gain. Patient will present with clear breath sounds and a normal respiratory rate. Patient verbalizes understanding of the importance of fluid restrictions if ordered. Patient verbalizes how to monitor for excess fluid volume. | 1. Enforce fluid restrictions and educate on the importance. If a fluid restriction is ordered, the nurse should educate the patient and their family on the reason for better adherence. Fluid restrictions prevent the patient from taking in too much extra fluid. 2. Record accurate intake and output. Along with enforcing fluid restrictions, monitoring and recording accurate I&O is vital. All intake from IV fluids, water taken with medications, and meal intake need to be documented so it can be compared to the patient’s urine output. 3. Record daily weights. A patient at risk for fluid overload should have their weight monitored daily. This should be done at the same time each day using the same scale or bed scale. If at home, the patient should weigh themselves at the same time (preferably in the morning before eating and dressing). 4. Educate the patient and family on signs of fluid gain. Swelling in extremities, shortness of breath, needing to sleep sitting up (orthopnea), weight gain of 2 pounds in 24 hours or 5 pounds in a week, and observed mental status changes are signs of fluid retention and overload. 5. Administer diuretics. Diuretics rid the body of excess sodium and water in the body. This can relieve high blood pressure, edema, and shortness of breath. 6. Review dietary restrictions. Patients may be on a low or restricted sodium diet. Monitor for appropriate meals, provide salt substitutes and educate on diet changes such as reading food labels, restricting fast or frozen foods and eliminating table salt. 7. Assist with procedures such as paracentesis or dialysis. Patients with liver failure may require the removal of fluid from their abdomen (ascites) via a paracentesis to relieve pressure and other symptoms. Dialysis removes waste and excess fluid from patients with kidney failure. | Patient displayed normal fluid volume as evidenced by balanced intake and output. Patient will display no signs of edema or sudden weight gain. Patient presented with clear breath sounds and a normal respiratory rate. Patient verbalized that he/she understood the importance of fluid restrictions as ordered. Patient verbalized how to monitor for excess fluid volume. |