Nursing Care Plan Assessment Cues: Subjective Namamaga ata paa ko as verbalized by the patient.

. Objective Edema Distended jugular vein V/S BP: 180/70mmHg Temp: 37.0 C RR: 24 cpm Pulse: 125 bpm Nursing Diagnosis Fluid Volume Excess related to decrease GFR. Planning After 4 to 8 hours of nursing interventions the patient will monitor his fluid status and reduce his fluid excess Intervention Independent - Monitor and
record vital signs -Assess possible risk factors -Evaluate mentation for confusion and personality changes -Observe skin mucous membrane -Review lab data like BUN, creatinine, Serum electrolyte -Record I&Os Dependent -Administer any medication/drugs as ordered by the doctor.

Rationale

Evaluaton The patient was able to monitor his I&Os and reduced his fluid excess indicated by an equal intake and output.

-To obtain baseline data -To obtain baseline date -To evaluate degree of fluid excess -To prevent pressure ulcers -To lessen fluid retention and overload. -Weight gain indicates fluid retention. -To lower fluid excess, and to decrease the risk factors.

Assessment

Nursing Diagnosis

Planning

Intervention

Rationale

Evaluaton

Cues: Subjective None Objective Increased in Lab results (BUN, Creatinine) Oliguria V/S BP: 180/100mmHg Temp: 36.8 C RR: 26 cpm Pulse: 130 bpm

Altered Renal Perfusion related to Increased BUN and Creatinine levels.

After 2-3 hours of nursing interventions, the patient will demonstrate participation in his recommended treatment program.

Independent -Monitor and Record V/S -To obtain baseline data

-Note characteristics -To assess for of urine. hematuria and proteinuria and renal impairment. -Monitor BP every -GFR may increase 15 minutes and raise BP -Measure I&Os on a -To assess renal regular schedule perfusion and function. -Give information -To provide about positive signs encouragement. of improvement such as V/S and circulation. -Encourage patient to maintain positive attitude, suggest guided imagery technique Dependent -Administer medication as ordered. Intervention -To enhance sense of well being.

After 2-3 hours of nursing interventions the patient was encouraged and was able to participate in his recommended program.

-To treat the clients disease condition. Rationale Evaluaton

Assessment

Nursing Diagnosis

Planning

Cues: Subjective None Objective >Increase in Lab results (Creatinine, BUN, Uric Acid Level) >Anuria V/S BP:180/100mm Hg Temp: 36.8 C RR: 26 cpm Pulse: 130 bpm

Impaired Urinary Elimination related to glomerular malfiltration.

After 8 hours of nursing interventions the patient will participate in measures to correct/compensate for defects.

Independent -Monitor and record V/S -Review for lab test for changes in renal function. -Determine clients pattern of elimination -Determine clients usual daily fluid intake -Encourage to verbalize fear/concerns -Emphasize the need to adhere with prescribed diet. -Emphasize the importance of adhering to treatment regimen. -Note condition of skin and mucous -To obtain baseline data -To assess for contributing or causative factors -To assess degree of interference -To help determine level of hydration -Open expression allows client to deal with feelings. -To prevent aggravation of diseases condition. -To promote wellness

After 8 hours of nursing interventions the patient was able to participate in the interventions to help correct his defects.

-To assess level of hydration

membranes, color of urine Dependent Administer medication as ordered. -To treat the clients disease condition.