VI. Nursing Diagnosis
• Fluid volume excess related to decreased urine output
• Activity intolerance related to fatigue, toxins and fluid build up
• Risk for impaired skin integrity related to edema, toxins, or impaired tissue perfusion
• Risk for infection related to intravenous lines or catheters or uremic toxins
• Deficient knowledge regarding condition and its treatment
VII. Nursing Management
Promote measures to ensure normal potassium levels.
• Monitor potassium level and assess for effects of hyperkalemia.
• Restrict dietary potassium as necessary.
• Monitor cardiac telemetry for electrocardiographic changes.
• Prepare to administer insulin and glucose, which drives potassium back into the cell.
Promote measures to maintain acid-base balance.
• Monitor for acidosis
• Administer an alkalinizing agent
• Monitor arterial blood gas values for signs of metabolic acidosis or alkalosis.
• Be prepared to institute ventilator measures if respiratory problems develop.
Promote measures to assess and prevent infection.
• Assess for infection, especially of the respiratory and urinary tracts.
• Do not leave the urinary catheter in place.
• Administer prophylactic antibiotics as prescribed.
• Monitor for hyperphosphatemia.
• Administer phosphate-binding agents.
• Monitor serum phosphorus level.
Promote measures to ensure normal calcium levels.
• Monitor for hypocalcemia
• Administer calcium supplements
• Assess for hypercalcemia by checking for Chvostek’s and Trousseau’s signs.
Prevent GI bleeding by administering histamine receptor antagonists and proton pump inhibitors.
Promote comfort and encourage bed rest to reduce exertion and metabolic rate. As prescribed, administer short-acting barbiturates to control pain, and assess for central nervous system complications such as drowsiness, confusion, delirium, coma, and convulsions.
Provide a high-calorie and low-protein diet, with hyperalimentation if the client cannot eat.
If indicated, prepare the client for dialysis to correct hyperkalemia, fluid overload, acidosis, or severe uremia.
Administer prescribed medication, which may include alkalinizing agents, antibiotics, phosphate-binding agents, ion exchange resins, calcium supplements, histamine receptor antagonists, and proton-pump inhibitors.
Promote measures to maintain fluid balance. Assess fluid balance, and restrict intake to 24-hour urine output plus 500 ml/day.
Promote measures to ensure normal sodium and phosphate levels. Instruct the client to restrict sodium intake, drink plenty of fluids, and follow a low-phosphate diet.