<: NURSING CARE PLANS :>

ASSESSMENT Subjective: Namamanas ako at ang hina ng katawan ko Objective: >Generalized edema >difficulty of breathing >Patient reports of Fatigue, weakness, and malaise V/S: T= 37.5 RR=24 bpm BP=190/160 mmHg PR=75 bpm NURSING DIAGNOSIS Fluid Volume Excess r/t decrease Glomerular filtration Rate and sodium retention RATIONALE Renal failure Decrease blood flow to kidneys Decrease perfusion in kidney Decrease urinary output Water retention Fluid volumes excess Long Term: After 3 days of nursing intervention the patient will manifest stabilize fluid volume AEB balance I & O, normal VS, stable weight, and free from signs of edema. 5.Note amount/rate of fluid intake from all sources 6. Compare current weight gain with admission or previous stated weight 7. auscultate for breath sounds 8. Record occurrence of dyspnea 9. Note presence of edema. 10. Measure abdominal girth for changes. 11. Evaluate mentation for confusion and personality changes. 12.Observe skin mucous membrane. 13.Change position of PLANNING Short Term: After 48 hours of nursing interventions, patient will demonstrate behaviors to monitor fluid status and reduce recurrence of fluid excess. INTERVENTION 1. Establish rapport. 2. Monitor and record vital signs. 3. Assess possible risk factors. 4. Assess patients appetite RATIONALE . >To assess precipitating and causative factors. >To obtain baseline data >To obtain baseline data EVALUATION Short Term: The patient shall have demonstrated behaviors to monitor fluid status and reduce recurrence of fluid excess

>To note for presence of nausea and vomiting Long Term: >To prevent fluid overload and monitor intake and output >To monitor fluid retention and evaluate degree of excess >For presence of crackles or congestion . >To evaluate degree of fluid excess >To determine fluid retention >May indicate increase in fluid retention >May indicate cerebral edema. >To evaluate degree of fluid excess. >To prevent pressure The patient shall have manifested stabilized fluid volume AEB balance I & O, normal VS, stable weight, and free from signs of edema.

client timely. 14. Review lab data like BUN, Creatinine, 15. Restrict sodium and fluid intake if indicated 16.Record I&O accurately and calculate fluid volume balance 17.Weigh client 18.Encourage quiet, restful atmosphere. 19.Promote overall health measures

ulcers. >To monitor fluid and electrolyte imbalances >To lessen fluid retention and overload.

>To monitor kidney function and fluid retention. >Weight gain indicates fluid retention or edema. >To conserve energy and lower tissue oxygen demand. >To promote wellness.

ASSESSMENT

NURSING DIAGNOSIS Impaired Urinary Elimination r/t glomerular Malfiltration & Impaired excretion of nitrogenous products secondary to Renal Failure

RATIONALE Renal Failure is a problem which results to loss of kidney functions and as GFR decrease, the kidney cannot excrete nitrogenous product and fluid causing impaired in Urinary elimination and together with prolonged use of medications such as NSAIDs this will lead to further kidney

PLANNING Short Term: After 23 hours of nursing interventions, the patient will verbalize understanding of condition.

INTERVENTION 1.Establish rapport. 2. Monitor and record vital signs. 3.Assess pts general condition 4.Review for laboratory test for changes in renal function. 5. Establish realistic

RATIONALE >To get the cooperation of the patient and SO. >To obtain baseline data. >To know what problem and interventions should be prioritize. >To assess for contributing or causative factors.

EVALUATION Short Term: The patient shall have demonstrated participation in his/her recommended treatment program

Objective: >Generalized edema >difficulty of breathing >Patient reports of Fatigue, weakness, and malaise >Increase in Lab results (BUN, Creatinine, Uric Acid Level) Oliguria-

Long Term: After 1-2 days of nursing interventions,

Long Term: The patient shall have demonstrated

anuria V/S: T= 37.5 RR=24 bpm BP=190/160 mmHg PR=75 bpm

destruction which may thus decreasing the glomerular filtration and destroying of the remaining nephrons. This will result into inability of the kidney to concentrate urine which makes the patient to have a nursing diagnosis of impaired urinary elimination.

the patient will participate in measures to correct/ compensate for defects

activity goal with client. 6.Determine clients pattern of Elimination. Palpate bladder 8.Investigate pain, noting location 9.Determine clients usual daily fluid intake 10.Note condition of skin and mucous membranes, color of urine. 11.Observe for signs of infection 12.Encourage to verbalize fear/concerns 13.Emphasize the need to adhere with prescribe diet 14.Emphasize importance of having good hygiene. 15.Emphasize importance of adhering to treatment regimen >To assess level of hydration. >To help in treating urinary alterations Open expression allows client to deal with feelings and begin problem solving. >To prevent aggravation of disease condition. >To promote wellness >Enhance commitments to promoting optimal outcomes. >To assess degree of interference . >To assess retention >To investigate extent of interference >To help determine level of hydration.

behavior/lifestyle changes to prevent complications

ASSESSMENT

NURSING DIAGNOSIS Altered Renal Perfusion r/t Glomerular Malfunction, Increase in BUN, Creatinine and

RATIONALE For optimal cell functioning the kidney excrete potentially harmful nitrogenous productUrea, Creatinine, Uric Acid

PLANNING Short Term: After 2-3 hours of NI, the patient will demonstrate participation in his/her recommended

INTERVENTION 1. Establish rapport 2.Monitor and record vital signs. 3. Assess patients

RATIONALE >To get the cooperation of the patient and SO. >To obtain baseline data

EVALUATION Short Term: The patient shall have demonstrated participation in his/her recommended treatment program

Objective: >Generalized edema >Increase in Lab

results (BUN, Creatinine, Uric Acid Level) >Oliguria- anuria >hypertension >Capillary refill time: 4 seconds V/S: T= 37.5 RR=24 bpm BP=190/160 mmHg PR=75 bpm

Uric Acid Level secondary to renal Failure.

but because of the loss of kidney excretory functions there is impaired excretion of nitrogenous waste product causing in increase in Laboratory result of BUN, Creatinine, Uric Acid Level

treatment program.

general condition. 4.Determine factors related to individual situation and note situation that can affect all body system. 5.Note characteristic of urine: measure urine specific gravity. 6.Ascertain usual voiding pattern 7. Note presence, location intensity duration of pain. 8. Note mental status and review lab result such as BUN and creatinine levels. 9. Monitor BP, ascertain patients usual range. 10. Observe for dependent generalized edema. 11. Measure urine output on a regular schedule and weigh daily. 12.Provide diet restriction as indicated, while providing adequate calories. 13.Encourage discussion of feelings regarding prognosis or long term effects of discussion. 14. Identify necessary changes in lifestyle and assist client to incorporate disease >To obtain baseline data. Long Term: >To assess causative and contributing factors The patient shall have demonstrated behavior/lifestyle changes to prevent complications.

Long Term: After 2-3 days of NI, the patient will demonstrate behavior/lifestyle changes to prevent complications

>To assess for hematuria and proteinuria and renal impairment. >To compare with current situation. >may indicate pain on affected organ >increase BUN and creatinine levels may alter Mental status >GFR may increase rennin and raise BP. >To note degree of impairment of renal function. >To assess renal perfusion and function. >Calories to meet bodys need while >restriction of protein helps limit BUN. >To decrease anxiety about condition and correct his wrong

management to ADLs. 15. Assess patient emotional/psychological factors affecting the current situation. 16.Establish realistic activity goal with patient.

ideas about condition. >To promote wellness and prevent further progression of complication. >Stress or depression may be increasing the effect of an illness or depression might be the result of being forced into inactivity. >Enhance commitments to promoting optical outcomes. >To provide encouragement.

17.Give information about positive signs of improvement such as improve vital signs/ circulation. 18.Provide physiologic support. Maintain calm attitude but admit concerns ifquestioned by the client/SO. 19.Review expectations of the patient/SO.

>Honestly can be reassuring when so much activity or worries apparent to the client or SO. >To sustain motivation.

20.Give patient information that provides evidence of daily/weekly progress. 21.Encourage patient to maintain positive attitude; suggest use of relaxation technique such as guided imagery as appropriate. 22.Administer medication

>To enhance sense of well being.

>For faster recovery. It is used to treat the clients disease condition.

as ordered. 23.Promote overall health measure.

>To promote wellness.

CARMINA SWEET B. BENDAA BSN4D :)