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NURSING CARE PLAN
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Nephrotic INDEPENDENT:
SUBJECTIVE: Excess fluid syndrome is a • After 8 hours • Record accurate • Accurate Intake • After 8 hours of
volume clinical disorder of of nursing intake and and output is nursing
“Namamanas related to unknown cause interventions, output of the necessary for interventions,
ang kanang compromised characterized by the patient will patient. determining the patient was
binti ng anak regulatory proteinuria, display stable renal function able to display
ko” (My son has mechanism hypoalbuminemia weight, vital and fluid stable weight,
a massive edema with changes , edema, and signs within replacement vital signs
on his lower right in hydrostatic hyperlipidemia. patient’s needs and within patient’s
leg) as or oncotic This conditions normal range, reducing risk of normal range,
verbalized by vascular result from and nearly fluid overload. and nearly
the mother. pressure and excessive absence of absence of
increased leakage of edema. • Monitor urine • Measures the edema.
OBJECTIVE: activation of plasma proteins specific gravity. kidney’s ability
the rennin- into the urine to concentrate
• Edema angiotensin- because of urine.
• Weight gain aldosterone impairment of the
• Changes in system. glomerular • Weigh daily at • Daily body
vital signs capillary same time of the weight is the
• V/S taken membrane. day, on same best monitor of
as follows: scale, with same fluid status. A
equipment and weight gain of
T: 37.3 clothing. more than 0.5
P: 85 kg/day suggest
R: 21 fluid retention.

• Assess skin, • Edema occurs


face, dependent primarily in
areas of edema. dependent
tissues of the
body. It will
serve as
parameter the
Nursingcrib.com – Student Nurses’ Community
severity of fluid
excess.

• Monitor heart • Tachycardia and


rate and blood hypertension
pressure. can occur
because of
failure of the
kidneys to
excrete urine.

• Assess level of • May reflect fluid


consciousness; shifts and
investigate electrolyte
changes in imbalances.
mentation,
presence of
restlessness.

COLLABORATIVE:
• Monitor • Provide
laboratory and assessment of
diagnostic the progression
studies. and
management of
the dysfunction.

• Administer • To promote
diuretics as adequate urine
prescribed. volume that aids
in prevention of
further edema.