If a client comes in and has chronic renal failure, then the nurse recognizes that this client is having severe problems with his kidneys. This means that the kidneys are not functioning properly and may fail. The kidneys have an important function which is to flush out the waste.
The way it does that is with water or fluid. The client may have a heart rate of one hundred twenty-two beats per minute and a respiratory rate of thirty-two breaths per minute. He has a blood pressure of one hundred ninety over one hundred ten. He has jugular vein distention and bibasilar crackles. The nurse’s diagnosis that is of the utmost priority would be to have excess fluid volume so that the kidney would do their job.
Excess fluid volume-rationale: a client with renal failure cant eliminate sufficient fluid. this issue increases his risk of fluid overload and consequent respiratory and electrolyte problems. this client shows signs of excess fluid volume and is acutely ill. urine retention may cause renal failure but is a less urgent concern than fluid imbalance. fear and toileting self-care deficit may also be appropriate nursing diagnoses but they take lower priority because they arent life-threatening. client needs category: physiological integrity client needs subcategory: reduction of risk potential cognitive level: application reference: craven, r.f., and hirnle, c.j. fundamentals of nursing: human health and function, 5th ed. philadelphia: lippincott williams & wilkins, 2007, p. 942.
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