Nursing Care Plan

1. Assessment
Subjective

Nursing Diagnosis
Fluid volume excess r/t retention of sodium and water

Rationale
The kidneys cannot concentrate or dilute urine normally.

Planning
The pt. will be able to stabilize fluid volume as evidenced by balanced I & O, stable weight and free of signs of edema.

Nursing Interventions
1. Assess fluid status: a. weight daily b. I & O c. presence of edema

Rationale
1. Assessment provides baseline and ongoing database for monitoring changes and evaluating interventions. 2. Fluid restriction will be determined on basis of weight, urine output, and response to therapy. 3. Unrecognized sources of excess fluids may be identified

Evaluation

Objective Bipedal edema

Brunner & Suddarths (2010).Medical Surgical Nursing 12th edition .vol.2.Lippincott Williams & Wilkins p. 1325

2. Limit fluid intake to prescribed volume.

3. identify potential sources of fluid: a. Medications and fluids used to administer medications: oral and IV. b. Foods 4. Restrict sodium as indicated.

4. Sodium is not excreted due to kidney failure and it retains water w/c will aggravate the condition. 5. Oral hygiene minimizes dryness and discomfort of oral mucous membrane due to fluid restriction.

5. Provide or encourage frequent oral hygiene

2. Assessment
Subjective

Nursing Diagnosis
Imbalanced nutrition: less than body requirements r/t dietary restrictions

Rationale
This is due to impaired absorption of electrolytes because of renal failure.

Planning
The patient will be able to maintain adequate nutritional intake and display normalization of laboratory values

Nursing Interventions
1. Assess nutritional status: a. weight changes b. lab values (BUN, creatinine, serum electrolyte, protein and iron levels) 2. Assess for factors contributing to altered nutritional intake: a. diet is unpalatable to patient b. depression 3. Promote pleasant, relaxing environment & prevent or minimize unpleasant odors or sight. 4. Provide patients food preferences w/i dietary restrictions. 5. Encourage highcalorie, low- protein and low-potassium snacks bet. Meals.

Rationale
1. Baseline parameters

Evaluation

Objective
Brunner & Suddarths (2010).Medical Surgical Nursing 12th edition.vol.2.Lippincott Williams & Wilkins p.1324

2. Information about other factors maybe altered or eliminated to promote adequate dietary intake.

3. To enhance intake & prevent negative effects on appetite and eating

4. To increase dietary intake 5. Reduces source of restricted foods and proteins and provides calories for energy , sparing the protein for tissue growth and healing.

3. Assessment
Subjective

Nursing Diagnosis
Risk for Activity intolerance r/t imbalance O2 supply and demand (anemia)

Rationale
This is a result of inadequate erythropoietin production and shortened lifespan of RBCs. And so, there will be a decrease in oxygenated blood RBCs which may cause hypoxia & DOB/SOB.

Planning
The patient will be able to participate in activity within tolerance perform activity of daily living within clients ability and participates

Nursing Interventions
1. Assess factors contributing to activity intolerance: a. fatigue b. depression 2. Evaluate/ assess clients activity level and physical condition 3. Promote independence in selfcare activities as tolerated: assist if fatigued. 4. Encourage alternating activity with rest. 1.

Rationale

Evaluation

Objective Difficulty of breating

2. To provide baseline for comparison & to know the energy limitation 3. Promotes improved self-esteem and independence.

4. Promotes activity and exercise w/i limits and adequate rest and to reduce fatigue 5. To prevent unwanted injuries

5. Assist patient w/ activities and provide safety measures.

4.

Assessment
Subjective

Nursing Diagnosis
Risk for Bleeding r/t Anemia

Rationale

Planning
The patient will be able to

Nursing Interventions
1. Monitor RBC count, hemoglobin and hematocrit levels as indicated. 2. Administer medications as prescribed, including iron and folic acid supplements, Epogen and multivitamins 3. Avoid drawing unnecessary blood specimens 4. teach patient to prevent bleeding: Avoid vigorous nose blowing and contact sports and use a soft toothbrush 5. Administer blood component therapy

Rationale
1. Provides assessment of degree of anemia

Evaluation

Objective

2. RBCs needed iron, folic acid, and vitamins to be produced. Epogen stimulates the bone marrow to produce RBC.

3. Anemia is worsen by drawing numerous specimens. 4. Bleeding from anywhere in the body worsen anemia.

5. Blood component therapy may be needed if some patient has symptoms

5.

Assessment Subjective hindi ako sanay matulog as ospital as verbalized

Nursing Diagnosis Disturbed sleeping pattern related to paroxysmal nocturnal dyspnea secondary to unfamiliar sleep surroundings

Rationale

Planning
The patient will be able to report improved sleep and rest.

Nursing Interventions 1. Elevate the head of the bed.

Rationale 1 to decrease the pressure in the lungs and promote lung expansion 2. to 2. to promote physical comfort

Evaluation

2. administer O2 2. promote bedtime care (such as straightening bed sheets and changing gowns or dress) 2. minimize sleepdisturbing factors (noise and extreme temperature) 3. discuss and implement effective age-appropriate bedtime rituals 4. recommend light bed time snack (within dietary restriction)

Objective

2. to promote readiness for sleep and improve sleep duration and quality 3. to enhance patients ability to fall asleep

4. Sense of fullness and satiety promotes sleep.

5. recommend 5. Milk contains drinking of milk with trypsin which acts as honey before sleeping sedative to promote sleep.