Nursing diagnosis: excess Fluid Volume related to compromised regulatory mechanism (renal failure)
Possibly evidenced by
Intake greater than output, oliguria; changes in urine specific gravity
Venous distention; blood pressure (BP) and central venous pressure (CVP) changes
Generalized tissue edema, weight gain
Changes in mental status, restlessness
Decreased Hgb/Hct, altered electrolytes, pulmonary congestion on x-ray
Desired Outcomes/Evaluation Criteria—Client Will
Fluid Overload Severity
Display appropriate urinary output with specific gravity and other laboratory studies near normal; stable weight and vital signs within client’s normal range; and absence of edema.
Nursing intervention with rationale:
1. Record accurate intake and output (I&O). Include “hidden” fluids, such as intravenous (IV) antibiotic additives, liquid medications, ice chips, and frozen treats. Measure GI losses and estimate insensible losses, such as diaphoresis.
Rationale: Low urine output less than 400 mL/24 hours may be first indicator of acute failure, especially in a high-risk client. Accurate I&O is necessary for determining fluid replacement needs and reducing risk of fluid overload. Note: Hypervolemia occurs in the anuric phase of ARF.
2. Monitor urine specific gravity.
Rationale: Measures the kidney’s ability to concentrate urine. In intrarenal failure, specific gravity is usually equal to or less than 1.010, indicating loss of ability to concentrate the urine.
3. Weigh daily at same time of day, on same scale, with same equipment and clothing.
Rationale: Daily body weight is best monitor of fluid status. A weight gain of more than 0.5 kg/day suggests fluid retention.
4. Assess skin, face, and dependent areas for edema. Evaluate degree of edema (on scale of +1 to +4).
Rationale: Edema occurs primarily in dependent tissues of the body, such as hands, feet, and lumbosacral area. Client can gain up to 10 lb (4.5 kg) of fluid before pitting edema is detected. Periorbital edema may be a presenting sign of this fluid shift because these fragile tissues are easily distended by even minimal fluid accumulation.
5. Monitor heart rate, BP, and CVP.
Rationale: Tachycardia and hypertension can occur because of (1) failure of the kidneys to excrete urine, (2) excessive fluid resuscitation during efforts to treat hypovolemia or hypotension, and (3) changes in the renin-angiotensin system, which helps regulate long-term blood pressure and blood volume. Note: Invasive monitoring may be needed for assessing intravascular volume, especially in clients with poor cardiac function.
6. Auscultate lung and heart sounds.
Rationale: Fluid overload may lead to pulmonary edema and HF, as evidenced by development of adventitious breath sounds and extra heart sounds.
7. Assess level of consciousness; investigate changes in mentation and presence of restlessness.
Rationale: May reflect fluid shifts, accumulation of toxins, acidosis, electrolyte imbalances, or developing hypoxia.
8. Plan oral fluid replacement with client, within multiple restrictions. Intersperse desired beverages throughout 24 hours. Vary offerings, such as hot, cold, and frozen.
Rationale: Helps avoid periods without fluids, minimizes boredom of limited choices, and reduces sense of deprivation and thirst.
9. Correct any reversible cause of ARF, such as replacing blood losses, maximizing cardiac output, discontinuing nephrotoxic drug, and removing obstruction via surgery.
Rationale: Kidneys may be able to return to normal functioning, thus preventing or limiting long-term residual effects.
10. Insert and maintain indwelling catheter, as indicated.
Rationale: Catheterization excludes lower tract obstruction and provides means of accurate monitoring of urine output during acute phase; however, indwelling catheterization may be contraindicated because of increased risk of infection.