Risk for Excess Fluid Volume related to water and sodium retention and renal dysfunction.
Purpose: The client no signs of excess fluid volume.
Interventions:
1. Monitor and report signs and symptoms of fluid overload: Measure and record intake and output every 4-8 hours.
2. Record the number and characteristics of urine. Measure the specific gravity of urine every hour and measure body weight per day.
3. Collaboration with nutrients in dietary sodium and protein restriction.
4. Monitor the client's body electrolytes and observation for signs of electrolyte deficiency in the body.
- Hypokalemia: abdominal cramps, lethargy, arrhythmia
- Hyperkalemia: muscle cramps, weakness
- Hypocalcemia: sensitive excitatory on neuromuscular
- Hyperphosphatemia: hyperflexion, paresthesias, muscle cramps, itching, seizures
- Uremia: chaotic mental, lethargy, restlessness
Rationale:
- Monitor the excess liquid so that remedial action can be done.
- The number, characteristics of urine, and weight gain can indicate fluid imbalance.
- Sodium and protein increase the osmolarity so that no fluid restriction.
- Monitor their electrolyte imbalance and determine appropriate remedial action.
- Giving proper electrolyte can prevent electrolyte imbalance.
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