NURSING CARE PLAN

Identified Problem: oliguria Nursing Diagnosis: Ineffective renal tissue perfusion r/t decreased nephronal function 2 0 chronic kidney disease CUES Subjective: Sige kog ihi-ihi na taggagmay., pt. verbalized. Objective: OBJECTIVES Short Term Objective: Within 8 hours of rendering appropriate nursing care, pt will be able to verbalize understanding of condition, therapy regimen, side effects of medications, and when to contact healthcare provider. Long Term Objective: Within 2 days of rendering nursing care, patient will be able to demonstrate increased perfusion as individually appropriate as evidenced by vital signs within normal range and balanced intake and output. INTERVENTIONS RATIONALE EVALUATION

-oliguria -increased creatinine levels -lumbar pain -weakness -fatigue -hematuria -pyuria Labs: Blood chem Creatinine=2.4mg/dl (N=0.6-1.2mg/dl) Urinalysis Pus cells=6-14/hpf Rbc cells=15.33/hpf Vital signs: T= 37.9 0C PR=84 bpm RR=26 cpm BP=90/50 mmhg

1. Monitor vital signs regularly. 2. Monitor and regulate IVF and intake and output. 3. Ascertain usual voiding pattern and compare with current situation. 4. Note characteristics of urine and measure specific gravity. 5. Provide for fluid and diet restrictions, as indicated, while providing adequate calories and hydration. 6. Encourage client to quit smoking. 7. Identify necessary changes in lifestyle and assist client to incorporate disease management into ADLs. 8. Demonstrate / Encourage use of relaxation techniques. Collaborative: 9. Administered medications as prescribed.

1. For baseline data. 2. To prevent fluid imbalance. 3. To note changes such as low output, hematuria,etc. 4. To evaluate kidneys ability to concentrate urine. 5. To meet the bodys needs without overtaxing the kidney function. 6. Smoking causes vasoconstriction compromising perfusion. 7. Promotes independence, enhances self-concept regarding ability to deal with change and manage own needs. 8. To decrease tension level. 9. To treat underlying condition.

STO: Outcome met. After 8 hours of rendering appropriate nursing care, pt verbalized understanding of condition, therapy regimen, side effects of meds and when to contact healthcare provider. LTO: Outcome partially met. After 2 days of rendering nursing care, pt demonstrated a slight increase in perfusion AEB output is almost equal to the intake of the patient and the ff. V/S: T- 37.4 C0, PR80bpm, RR- 24cpm, BP- 100/70mmhg.

NURSING CARE PLAN

Identified Problem: Oliguria Nursing Diagnosis: Altered Urinary Elimination R/T Glomerular Malfiltration as evidenced byImpaired excretion of nitrogenous products

2O Renal Failure
CUES Subjective: Ginagmay ra akuang ihi.. as verbalized by patient. OBJECTIVES Short Term Objective: Within 2 hours of rendering nursing care, the patient will be able to verbalize the understanding of condition. INTERVENTIONS RATIONALE EVALUATION

1. Monitored v/s 2. Monitored and Regulated IVF 3. Monitored Intake and output 4. Encouraged fluid Intake of 3,000-4,ooo mL/day 5. Encouraged client to void in a sitz bath position 6. Provided timed verbal voiding

1. To provide baseline data 2. To Provide Hydration

Outcome met:

3. 4.

Objective: Oliguria Hesitancy Urinary Retention Increase in Lab results: Creatinine 335umol/L Presence of Albumin in the Urine Pus cells in the Urine 614/hpf RBC in the Urine 1533/hpf

Long Term Objective: Within 48 hours of rendering nursing care, patient will be able to participate in measures to correct problems as evidenced by Increased volume of urine eliminated,absence of albumin, pus cells and RBC in the urine and a normal level of creatinine.

5.

6.

Within 2 hours of rendering nursing care, the patient was able to To assess presence of verbalize the fluid imbalance understanding of condition. To improve renal function Outcome not met: Within 48 hours of Warm water helps rendering nursing relax smooth muscles care, patient was able to participate in measures to To prevent urinary correct problems stasis but were not manifested by increased volume of urine eliminated, absence of albumin, pus cells and RC in the urine and still an abnormal level of creatinine.

NURSING CARE PLAN

Identified Problem: body malaise Nursing Diagnosis: fatigue r/t deteriorating health condition 2 0 chronic kidney disease

CUES Subjective: Luya man ako paminaw, pt. verbalized.

OBJECTIVES Short Term Objective: Within 30 minutes of providing health teaching, patient will be able to verbalize understanding of the disease process, individual risk factors and treatment plan.

INTERVENTIONS 1. Monitored vital signs and IVF of patients. 2. Monitor laboratory findings/diagnostic studies. 3. Keep client on bed or chair rest in position of comfort. 4. Maintain calm attitude and limit stressful stimuli. 5. Provide adequate time for rest. 6. Encouraged changing of position slowly 7. Encourage relaxation techniques. 8. Avoid prolonged sitting position for all clients. 9. Establish an environment conducive for sleep. 10. Administer medications, as appropriate.

RATIONALE 1. To monitor the progression of the disease process and the hydration status of the patient. 2. Imbalances can alter electrical conduction and cardiac function. 3. To reduce catecholamineinduced stress response and cardiac workload. 4. To minimize environmental stressors. 5. To decrease oxygen consumption/demand, reducing myocardial workload. 6. To reduce risk of orthostatic hypotension. 7. To reduce anxiety. 8. To maximize vascular return. 9. To promote rest and sleep. 10. To aid in treating

EVALUATION Short Term Objective: Within 30 minutes of providing health teaching, patient will be able to verbalize understanding of the disease process, individual risk factors and treatment plan. Long Term Objective: Outcome partially met. Within 2 days of rendering nursing care, patient was able to report a slight increase in energy but wasnt able to demonstrate an increase in activity tolerance.

Objective: Weakness Long Term Objective: Fatigue Decreased Within 2 days of hemoglobin count and rendering nursing care, hematocrit patient will be able feel an increase in energy Laboratories: and activity tolerance. - Hgb = 103 g/L - Hct = 0.31 VS: T= 37.9 0C PR=84 bpm RR=26 cpm BP=90/50 mmhg

underlying cause.