ASSESSMENT EXPLANATION OF OBEJECTIVE INTERVENTION RATIONALE EVALUATION
THE PROBLEM Subjective: • Nephritis refers to Short term: Independent: • Display inflammation of one • Increased • Record accurate • Low output (less appropriate “Namamanas or both kidneys. It urinary output. intake and output than 400ml/24 hr) urinary output ang binti ko” as can be caused by (I&O). is the first indicator with normal infection, but is verbalized by the • Minimize of acute renal specific gravity most commonly patient. presence of failure. and laboratory caused by autoimmune edema. • Monitor urine • To measure the status within Objective: disorders that affect specific gravity. kidney’s ability to normal range. • Oliguria. the major organs. • Achieve stable concentrate urine. • Absence of For example, those weight and • Weigh daily at the • Daily body weight edema and • Weight gain. with lupus are at a stable vital same time of the is best monitor of body weight much higher risk for signs. day. fluid status. A returns to T : 36.4 developing weight gain of normal. P : 98 nephritis. In rare Long term: more than 0.5kg/ • Vital signs cases nephritis can R : 18 be genetically • Prevents day suggest fluid within normal BP: 130/80 complication retention. range. inherited, though it may not present in of the disease. • Monitor heart rate • Tachycardia and childhood. As the and Bp. hypertension can kidneys inflame, occur because of they begin to failure of the excrete needed kidney to excrete protein from the urine. body into the urine • Elevate edematous • To promote stream. Nephritis body part. venous return. also causes additional problems like water retention, Collaborative: as the kidneys • Monitor serum • Hyponatremia may cannot function sodium. result from fluid properly to rid the overload or body of water. kidney’s inability to Water retention or conserve sodium. edema, can further Hypernatremia cause swelling of indicates total the feet, ankles, body water legs, and hands. deficits. • Monitor serum • Lack of renal potassium. excretion and selective retention of potassium to excrete excess hydrogen ions lead to hyperkalemia requiring prompt treatment. • Administer diuretics. • To promote adequate urine volume.
After 8 hours of nursing interventions, the patient was able to demonstrate behaviors and lifestyle changes to reduce risk factors and protect self from injury