What is the most important nursing diagnosis for a patient in end-stage renal disease?
A. Risk for injury
B. Fluid volume excess
C. Altered nutrition: less than body requirements
D. Activity intolerance
Correct Answer: B. Fluid volume excess
Kidneys are unable to rid the body of excess fluids which results in fluid volume excess during ESRD. Renal disorder impairs glomerular filtration that results in fluid overload. With fluid volume excess, hydrostatic pressure is higher than the usual pushing excess fluids into the interstitial spaces. Since fluids are not reabsorbed at the venous end, fluid volume overloads the lymph system and stays in the interstitial spaces.
Option A: Assess I&O, electrolyte panel, and creatinine; administer diuretics as ordered. Provides an indication of renal function affecting output with water and electrolyte retention as the disease progresses and nephrons are destroyed.
Option C: Due to restricted foods and prescribed dietary regimen, an individual experiencing renal problems cannot maintain ideal body weight and sufficient nutrition. At the same time, patients may experience anemia due to decreased erythropoietic factors that cause a decrease in the production of RBC causing anemia and fatigue.
Option D: Assess the extent of weakness, fatigue, ability to participate in active and passive activities. Provides information about the impact of activities on fatigue and energy reserves. Schedule care and provide rest periods following an activity; allow the client to set their own limits in the amount of exertion tolerated.
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