Chronic Kidney Disease
Sample —for ideas only. Your own case → Create.
| Assessment data (subjective and objective findings relevant to THIS diagnosis) | Goals / expected outcomes | Nursing intervention | Rationale | Evaluation |
|---|---|---|---|---|
| Patient reports swelling in feet and hands; physical exam reveals peripheral edema; daily weights show increase of 2 kg in 3 days; decreased urine output noted; lung auscultation may reveal crackles. | Patient will maintain fluid balance as evidenced by stable weight, absence of edema, and adequate urine output within 24-48 hours. | Monitor daily weight at the same time each day using the same scale. | Daily weights help detect fluid retention or loss early, guiding treatment. | Weight remains stable or decreases, indicating controlled fluid volume. |
| Assess for signs of fluid overload such as edema, lung sounds, and blood pressure changes. | Early detection of fluid overload prevents complications like pulmonary edema. | No new or worsening edema or respiratory distress noted. | ||
| Encourage adherence to prescribed fluid restrictions and explain rationale. | Limiting fluid intake reduces risk of fluid overload and related complications. | Patient verbalizes understanding and follows fluid restriction guidelines. | ||
| Elevate edematous limbs to promote venous return and reduce swelling. | Elevation helps decrease peripheral edema by aiding fluid reabsorption. | Reduction in limb swelling observed. | ||
| Monitor intake and output accurately every shift. | Tracking fluid balance assists in managing excess fluid volume. | Intake and output records are accurate and balanced appropriately. |
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