Assessment Subjective: Nagmamanas lang ako nung una at ngayon naman ay minsan nahihirapan na akong huminga (I am only having

edema before but now sometimes I have some difficulty in breathing...) verbatim of client. Objective: Easy fatigability Weakness Shortness of breath Weight gain as claimed Anorexia History of glomerulonephritis when she was still a child Urinalysis showed proteinuria Hematologic lab results indicate decreased Hgb and Hct counts. Latest blood pressure : 150/100mmHg Latest respiratory rate: 25 breaths/min.

NURSING CARE PLAN FOR RENAL FAILURE Outcome Nursing Rationale Interventions -Assess clients - Provides baseline Impaired Gas Renal failure affects After 8 hours of respiratory rate, depth data of clients Exchange related to the function of the nursing care, the and use of accessory complain and degree decreased red blood kidneys. It is a client will be able muscles. of respiratory cell production and gradual progressive to show an compromise. reduction in the condition which improved gas - Monitor vital signs - It could help assess oxygen carrying primarily a result exchange as and check for the clients need for capacity of the from ischemia, evidenced by fluctuations in RR, blood transfusion blood secondary to inflammatory decreased PR, and BP. Presence therapy. disease process. processes, or episodes of of hypovolemia may nephrotoxicity. dyspnea/ show a drop in BP shortness of and some The destruction in the breath and tachycardia. glomerular filtration improved -Assisting client and basically influences tolerance to - Assess ability and limiting activity may the ability of the simple activity. tolerance to activity; help reduce the kidneys to filter the assist client in oxygen demand of blood flowing in the ambulation or limit the body, reducing renal blood vessels. stressful activity shortness of breath In addition, the depending on clients episodes. damage in the tolerance. - Placing client in a nephrons progresses fowlers position and its ability to -Place client in assist in the proper secrete erythropoietin fowlers position, chest expansion. decline. elevating head while Erythropoietin is a maintaining comfort. -Supplemental hormone that prompts oxygen aids in the bone marrow - Provide minimizing the increase red blood supplemental oxygen increased need of the cell production. as indicated, i.e. O2 body for oxygen, Obviously, the at 2liters per min. depending on decline in renal situational function often leads requirement. to chronic anemia. -Provide a quiet non - It promotes stimulating adequate resting environment. periods for the client. -Chronic anemia in Nursing Diagnosis Inference

Evaluation

After 8 hours of nursing care, the goals were partially met as evidenced by reduction of episodes of dyspnea when client had enough rest but still complains of shortness of breath upon going to the rest room even with assistance.

-Assist in transfusion therapies as indicated.

renal failure is treated with transfusion of blood to compensate for the renal compromise.