The nurse assesses the client who has chronic renal failure and notes the following: crackles in the lung bases, elevated blood pressure, and weight gain of 2 pounds in one day. Based on these data, which of the following nursing diagnoses is appropriate?
A. Excess fluid volume related to the kidney’s inability to maintain fluid balance.
B. Increased cardiac output related to fluid overload.
C. Ineffective tissue perfusion related to interrupted arterial blood flow.
D. Ineffective Therapeutic Regimen Management related to lack of knowledge about therapy.
Correct Answer: A. Excess fluid volume related to the kidney’s inability to maintain fluid balance.
Crackles in the lungs, weight gain, and elevated blood pressure are indicators of excess fluid volume, a common complication in chronic renal failure. The client’s fluid status should be monitored carefully for imbalances on an ongoing basis. 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.
Option B: The symptoms described do not indicate an increase in cardiac output. Auscultate heart and lung sounds. Evaluate the presence of peripheral edema, vascular congestion, and reports of dyspnea. S3 and S4 heart sounds with muffled tones, tachycardia, irregular heart rate, tachypnea, dyspnea, crackles, wheezes, edema, and jugular distension suggest HF.
Option C: For optimal cell functioning the kidneys excrete potentially harmful nitrogenous products – urea, creatinine, and uric acid. But because of the loss of kidney excretory functions, there is impaired excretion of nitrogenous waste products causing an increase in laboratory results of BUN, creatinine, and uric acid.
Option D: If fluid retention is a problem, the patient may need to restrict intake of fluid to 1100 cc (or less) and restrict dietary sodium. If a fluid overload is present, diuretic therapy or dialysis will be part of the regimen. Incidence of hypertension is increased in CRF, often requiring management with antihypertensive drugs, necessitating close observation of treatment effects (vascular response to medication).
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