a. Nursing care considerations are the same as for a patient with chronic renal failure, remembering at all times that changes in status may occur very rapidly.

For this reason, intense and vigilant nursing observation is required.

b. Fluid replacement therapy will be based on the patient’s weight, urinary output, and insensible losses. I & O must be accurate in order for the physician to prescribe the correct amount of IV fluids and P.O. intake.

c. The patient must be continually assessed for fluid retention.

(1) Auscultate lungs for the presence of fluid.

(2) Observe for dependent edema.

d. Assess for circulatory overload to avoid damage to the heart and lungs. Observe for:

(1) Distended neck veins.

(2) Dyspnea.

(3) Orthopnea.

(4) Pulmonary congestion.

(5) Tachycardia.

(6) Hypertension.