PRIORITIZATION JUSTIFICATION
1) Excess fluid volume related to - Based on the patient's condition,
decreased circulation in the excess fluid volume is
kidneys as evidenced by bipedal evidenced by bipedal edema
due to increased total body
edema
water. This fluid overload occurs
in the patient because there is a
decreased circulation in the
kidneys, which cannot filter the
blood, and when the body
cannot expel fluid. There is
retention because the kidneys
cannot remove waste material,
including fluids and sodium.
Therefore leads to sodium
retention, which attracts the
water to stay. Furthermore, Fluid
Overload can cause
complications if left untreated,
including worsening kidneys,
heart, and lung function. Health
is under safety and security on
Maslow's hierarchy of needs. It
must be prioritized so that
complications do not arise, such
as our next nursing priorities,
hyperkalemia and
hyponatremia.
2) Hyperkalemia related to reduced - As we can see in the patient's
renal excretion as evidenced by case, the potassium level has
shortness of breath and risen due to the patient's fluid
retention. Hyperkalemia is a
tachycardia
common complication of acute
kidney injury, particularly in
oliguric AKI. This nursing
problem identified is the second
priority in rendering
interventions to alleviate the
condition because potassium
levels in the body are higher
than the normal range.
Impairment in potassium
excretion due to renal
dysfunction can lead to fatal
cardiac arrhythmias, muscle
weakness, or paralysis with a
greater risk for adverse
outcomes. A patient with
hyperkalemia needs close
cardiac monitoring and
management as extremely high
levels can cause cardiac arrest,
requiring immediate medical
care and further worsening the
patient's condition.
3) Hyponatremia related to sodium - Sodium is an essential
retention as evidenced by extracellular electrolyte. It helps
diaphoresis maintain fluid balance, and it
also plays a crucial role in nerve
and muscle function.
Hyponatremia is our least
priority because our priority
nursing diagnosis is Excess fluid
volume deficit. This diagnosis
may be treated there already.
However, when the sodium level
drops, the water in the
bloodstream moves into the
cells, causing them to swell, and
this swelling can cause many
health concerns and can be life-
threatening.
Prioritization
1.
Cues and Explanatio STO & Nursing Rationale Evaluation
Nursing n of the LTO Interventions
Diagnosis problem
PRIORITY: Acute Goal of DIAGNOSTIC: Goal fully
Excess fluid kidney care: met: If the
volume related to injury Patient >Review patient’s Such patient
impairs will history to information explains
decreased
glomerular display determine the can assist measures
circulation in the filtration appropria that can be
probable cause of direct
kidneys as that results te urinary taken to treat
the fluid management.
evidenced by in excess output or prevent
imbalance. History may
bipedal edema fluid with fluid volume
include
volume. specific excess,
increased
Subjective Data: With fluid gravity/la describes
fluids or
volume boratory symptoms
- Pain or sodium
excess, studies that indicate
pressure in hydrostatic near intake. the need to
the chest pressure is normal; >Monitor weight consult with
- higher than stable regularly using the >Sudden the health
usual, weight, same scale and weight gain care provider,
Objective data: pushing vital signs preferably at the may mean has balanced
same time of day fluid
- Tachycardi extra fluids within intake and
into the patient’s wearing the same retention. output, and
a with
interstitial normal amount of Different stable weight
hypertensi fluid range; clothing. scales and and vital
on spaces. and clothing may signs.
- Shortness Since the absence show false
of breath fluid is not of weight Partially met
reabsorbed edema. inconsistencie if: If the
- Diaphoresi
at the >Monitor input s. patient
s venous explains
and output >Excess fluid
end, fluid LTO: accordingly. volume is one measures
volume After 3 of the primary that can be
overloads days of taken to treat
problems that
the lymph nursing or prevent
may arise if a
system and interventi fluid volume
patient has a
stays in the ons, the excess,
interstitial patient heart describes
spaces will problem, symptoms
leading the manifest which the that indicate
patient to stabilize heart must the need to
have fluid pump for the consult with
edema. volume kidneys to the health
balance, excrete. This care provider
Normal means that but has an
I&O and patients with imbalance in
vital heart intake and
signs, problems output and
and free retain fluid in vital signs.
from the body.
edema Unmet: If the
>Review serum >All are patient wasn't
STO: electrolytes, urine indicators of able to
After 4-8 osmolality, and fluid status accomplish
hours of urine specific and guide all of the
nursing objectives
gravity. therapy.
interventi stated.
ons,
patient
will THERAPEUTIC:
demonstr
ate >Administered >Diuretics
behaviors diuretics as per aids in the
to physician’s order. excretion of
monitor excess body
fluid fluids.
status
and >Elevate >Elevation
reduce edematous increases
recurrenc extremities, and venous return
e of fluid handle with care. to the heart
excess. and, in turn,
decreases
edema.
Edematous
skin is more
susceptible to
injury.
>Place the patient >Raising the
in a semi-Fowler’s head of the
or high-Fowler’s bed provides
position. comfort in
breathing.
EDUCATIVE:
>Encourage the >These aids
need to use help promote
antiembolic venous return
stockings or and minimize
bandages, as fluid
ordered. accumulation
in the
extremities.
>Reiterate the
need for limiting >Restriction
sodium intake as of sodium
prescribed. aids in
decreasing
fluid retention
>Educate the
patient and family >Knowledge
members the heightens
importance of compliance
proper nutrition, with the
hydration, and treatment
diet modification. plan.
REFERENCE/S:
Brazier, Y. (2020, January 17). What to know about water retention.
MedicalNewsToday. https://www.medicalnewstoday.com/articles/187978
Vera, M. B. (2020, December 5). 6 Acute Renal Failure Nursing Care Plans.
Nurseslabs. https://nurseslabs.com/6-acute-renal-failure-nursing-care-plans/2/
Claure-Del Granado, R., & Mehta, R. L. (2016, August 2). Fluid overload in the
Icu: Evaluation and management. BMC Nephrology.
https://bmcnephrol.biomedcentral.com/articles/10.1186/s12882-016-0323-6.
S. Patil, Saurabh Gandhi, Piyush Prajapati, Shivraj Afzalpurkar, Patil, O. A., & M. Khatri. (2017). A
Study of Electrolyte Imbalance in Acute Myocardial Infarction Patients at A Tertiary Care Hospital in
Western Maharashtra. https://www.semanticscholar.org/paper/A-Study-of-Electrolyte-Imbalance-in-
Acute-Patients-Patil-Gandhi/3d3e1eea5a6e1fb445382d4c469ba66ebe69596f
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Medical.net. https://www.news-medical.net/health/Electrolyte-disturbance-and-acute-kidney-
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