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NURSING CARE PLAN

ASSESSMENT Subjective Cues: Masakit po at parang nangingilo ang legs ko, as verbalized by the patient. OBJECTIVE OF CARE At the end of 48 hours nursing intervention, the patient will be able to: NURSING INTERVENTION RATIONALE IMPLEMENTATION EVALUATION After implementing the nursing interventions: The patient have verbalized understanding of causative factors and demonstrated behaviors to resolve excess fluid volume.

Objective Cues verbalize assess patients general To determine assessed patients general - BP: 180/90 mmhg understanding of condition what approach to condition - T: 39C causative factors use in treatment - edematous leg of excess fluid - shortness of breath volume discuss the causative To give knowledge Discussed the causative - Urine Output: 500 factors of excess fluid factors of the excess fluid mL for 24 hour volume volume. period -Lab results: demonstrate monitor intake and I&O balance monitored intake and output Creatinine 6.3 adequate fluid output every 4 hours reflects fluid every 4 hours BUN 90 balance status Potassim 7.0

Nursing Diagnosis Fluid volume excess related to decrease urine out put and retention of sodium and water

weigh patient daily and compare to previous weights

Body weight is a weighed patient daily and sensitive compared to previous indicator of fluid weights balance and an increase indicates fluid volume excess

Auscultate breath When increased Auscultated breath sounds sounds q 2hr and pm for pulmonary q 2hr the presence of crackles capillary and monitor for frothy hydrostatic sputum production pressure exceeds oncotic pressure, fluid moves within the alveolar septum and is evidenced by the auscultation of crackles. Frothy, pink-tinged sputum is an indicator that the client is

developing pulmonary edema

Follow low-sodium diet Fluid restriction and/or fluid restriction may be used to decrease fluid intake, hence decreasing fluid volume excess.

Followed low-sodium diet and/or fluid restriction

Encourage or provide oral care q2

The client senses Encouraged or provide oral thirst because care q2 the body senses dehydration. Oral care can alleviate the sensation without an increase in fluid intake Inidicates fluid overload Monitored for distended neck veins and ascites

Monitor for distended neck veins and ascites

HEALTH TEACHING PLAN


SUBJECT MATTER: Acute Renal Failure TIME ALLOTMENT: 15 mins GENERAL OBJECTIVES: At the end of 15 minutes health teaching, the patient and his family will be able to acquire knowledge about acute renal failure. LEARNING OBJECTIVES At the end of health teaching, the patient should be able to: 1. Define acute renal failure The acute renal failure is an abrupt reduction in renal functions associated with oligurea (less than 400/day),fatigue,anorexia,nausea and vomiting 2 mins Explanation TIME ALLOTMENT

CONTENT

STRATEGIES

EVALUATION CRITERIA

ORAL QUESTIONING

In your own understanding, what is acute renal failure? -Ang acute renal failure po ay ang paunti-unting pagkawala ng function ng kidney natin. Can you give atleast 4 signs and symptoms? -fatigue -pagsusuka

2. Enumerate the signs and symptoms

Signs and Symptoms Oligurea (less than 400ml/day) Anuria(less than 50/day) Fatigue

4 mins

One on one discussion

3. Demonstrate understanding on the cause of acute renal failure

Anorexia Nausea Vomiting Increase creatinine and urea level in serum

-pagkonti ng dami ng ihi -walang ganang kumain

CAUSES AKI can be caused by disease, crush injury, contrast agents, some antibiotics, and more. The causes of acute kidney injury are commonly categorized into prerenal, intrinsic, and postrenal. Prerenal

6 mins

Explanation Any question about the causes of acute renal failure? -Wala po. Naiintidihan ko na isa sa mga rason kung bakit may acute renal failure ako ay dahil sa pagkakaroon ko ng diabetes.

Prerenal causes of AKI ("pre-renal azotemia") are

those that decrease effective blood flow to the kidney. These include systemic causes, such as low blood volume, low blood pressure, heart failure, and local changes to the blood vessels supplying the kidney. The latter include renal artery stenosis, or the narrowing of the renal arterywhich supplies the kidney with blood, and renal vein thrombosis, which is the formation of a blood clot in the renal vein that drains blood from the kidney. Intrinsic Sources of damage to the kidney itself are dubbed intrinsic. Intrinsic AKI can be due to damage to the glomeruli, renal tubules,

orinterstitium. Common causes of each are glomerulonephritis, acute tubular necrosis (ATN), and acute interstitial nephritis (AIN), respectively. A cause of intrinsic acute renal failure is tumor lysis syndrome.[7] Postrenal

Postrenal AKI is a consequence of urinary

tract obstruction. This may be related to benign prostatic hyperplasia, kidney stones, obstructed urinary catheter, bladder stone, bladder, ureteral or renal malignancy. It is useful to perform a bladder scan or a post void residual to rule out urinary retention.

DIET: 4. Identify the importance of diet Low sodium Diet People with acute renal failure can improve their symptoms by reducing the amount of salt (sodium) in their diet. Sodium is a mineral found in many foods. Eating too much salt causes the body to keep or retain too much water, worsening the fluid build-up associated with heart failure. 3 mins One on one discussion How will it help you? -Sa pamamagitan ng pagkain ng tama ay kahit papaano mababawasan ang aking paghihirap sa mga sintomas.

GENERIC NAME -Furosemide

INDICATION

SIDE EFFECTS

NURSING RESPONSIBILITIES Observe the 10 rights in administering medications. Assess fluid status. Notify physician or other health care professional if thirst, dry mouth, hypotension, or oliguria occurs. Monitor blood pressure and pulse before and during administration. Monitor blood glucose closely; may cause increased blood glucose level. Caution patient to change positions slowly to minimize orthostatic hypotension. Advise patient to contact health care professional immediately if muscle weakness, cramps,nausea, dizziness and numbness occurs.

CLASSIFICATION - Loop diuretics

Edema d/t heart failure, hepatic impairment or renal disease. Hypertension.

blurred vision, dizziness, head ache, vertigo

DOSAGE - 1 tablet, 200 mg

CONTRAINDICATIONS

ADVERSE EFFECTS

ROUTE -PO

Hypersensitivity; Cross-sensitivity with thiazides and sulfonamides may occur; Hepatic coma or anuria; Some liquid products may contain alcohol, avoid in patients with alcohol intolerance.

CNS blurred vision, dizziness, head ache, vertigo EENT hearing loss, tinnitus CV hypotension GI anorexia, constipation, diarrhea, dry mouth, nausea, vomiting GU excessive urination Derm photosensitivity, rash F and E dehydration

GENERIC NAME: - Norfloxacin

INDICATION

SIDE EFFECTS

NURSING RESPONSIBILITIES Observe the 10 rights in administering medications. Instuct patient to take the drug on an empty stomach. Teach patient to drink a lot of fluids. Advise patient to contact health care professional immediately if muscle weakness, cramps,nausea, dizziness and numbness occurs.

CLASSIFICATION - Antibiotic - Fluoroquinolone DOSAGE - 4oo mg


FREQUENCY: -Q12

For the treatment of adults with UTIs caused by susceptible bacteria. Prostatitis caused by E. coli

blurred vision, dizziness, head ache, vertigo

CONTRAINDICATIONS

ADVERSE EFFECTS

ROUTE -PO

Contraindicated with allergy to norfloxacin, nalidixic acid or cinoxacin; lactation; history of tendonitis or tendon rupture. Use cautiously in patients with renal impairment, seizures, pregnancy.

CNS headache, dizziness, insomnia, fatigue, somnolence, depression, blurred vision GI anorexia, constipation, diarrhea, dry mouth, nausea, vomiting

GENERIC NAME: - Amlodipine besylate

INDICATION

SIDE EFFECTS

NURSING RESPONSIBILITIES Observe the 10 rights in administering medications. Monitor patients BP carefully while adjusting drug to therapeutic doses. Administer drug without regard to meals. Instruct patient to report immediately if he will have irregular heartbeat, shortness of breath, swelling of feet or hands

CLASSIFICATION - Antianginal - Antihypertensive DOSAGE - 5 mg


FREQUENCY: -QID

Essential hypertension, alone or in combination with other antihypertensives. Also for chronic stable angina.

Nausea, vomiting and headache

CONTRAINDICATIONS

ADVERSE EFFECTS

ROUTE -PO

Contraindicated with allergy to amlodipine. Use cautiously with heart failure and pregnancy.

CNS light-headedness, dizziness, asthenia, fatigue, lethargy CV peripheral edema, arrythmias GI nausea, abdominal discomfort Dermatologic flushing, rash

GENERIC NAME: - Sodium Polystyrene Sulfonate

INDICATION

SIDE EFFECTS

NURSING RESPONSIBILITIES Observe the 10 rights in administering medications. Monitor serum electrolytes. Frequent blood tests will be needed to monitor drug effect. Report confusion, irregular heartbeats, constipation, severe GI upset.

Treatmentof hyperkalemia. CLASSIFICATION - Potassium removing resin DOSAGE - 15g


FREQUENCY: -QID

GI upset and constipation.

CONTRAINDICATIONS

ADVERSE EFFECTS

ROUTE -PO

Contraindicated with allergy to any component of the drug, obstructive bowel, severe hypertension, severe HF, marked edema.

GI constipation, fecal impacation, gastric irritation, anorexia, nausea, vomiting Hematologic Hypokalemia, electrolyte abnormalities

HEALTH PROBLEM Possible preeclampsia

FAMILY NURSING PROBLEM 1.Inability to recognize the possible complication in pregnancy due to lack of knowledge. 2.Inability to provide adequate nursing care to a pregnant member due to: a. Failure to comprehend the nature and magnitude of the condition. b.Low salience of theproblem/ condition.

GOAL OF CARE After nursing intervention, the family will be able to take the necessary measures to properly manage preeclampsia.

OBJECTIVES OF CARE After nursing intervention, thefamily will be able to:

INTERVENTIONS

IMPLEMENTATIO N

EVALUATION

1.Acquire information about the complication including the signs and symptoms.

1.Discuss with the family the causes, signs and symptoms, on complications of pre-eclampsia. RATIONALE: -To educate family about the disease condition. 2. Allow the family to verbalize doubts, questions and others which can hinder them from addressing the problem properly. RATIONALE: -To recognize thought of the family members and to provide understanding about their questions and doubts.

2. Enumerate the ways in preventing preeclampsia.

The goal of care was met since the family demonstrated > Discussed with the understanding family the causes, regarding the signs and symptoms, disease on complications of conditin and pre-eclampsia. ways to prevent it by answering all the questions > Allowed the family I asked for to verbalize doubts, each family questions and member. others which can hinder them from addressing the problem properly.

3. Name the foods that are prohibited to Mrs. Tan.

3. Discuss with the family the ways in preventing preeclampsia. RATIONALE: -To provide information about in preventing the disease. 4. Provide written information and selflearning modules for client to refer as necessary. RATIONALE: -Reinforces learning process, allows clients proceed at own pace.

> Discussed with the family the ways in preventing preeclampsia.

> Provided written information and self-learning modules for client to refer as necessary.