Medical Diagnosis: Chronic Kidney Disease Stage 5

Patients name:
Assessment Nursing
Diagnosis
Planning Interventions Rationale Evaluation
Subjective:
Nandito ako kasi
nahihirapan akong
huminga, lalo na pag
nagsasalita as
verbali!ed by the
patient
"bjective:
#atient $ani%ested:
&dema
'ypertension
(evidenced by
)#:
*+,-*,,mm'g.
#ulmonary
Congestion
(S"), D").
"liguria
/luid
0olume
&1cess r-t
sodium
retention
2%ter 345
hours o%
nursing
interventions,
patient 6ill
demonstrate
behaviours to
monitor %luid
status and
reduce
recurrence o%
%luid e1cess
*7 &stablish
rapport
87 $onitor and
record vital
signs
97 2ssess patient:s
appetite
37 Note
amount-rate i%
%luid intake %rom
all resources
57 ;ecord
occurrence o%
dyspnea
+7 Note presence
o% edema
<7 ;estrict sodium
and %luid intake
i% indicated
57 ;ecord = >"
accurately and
calculate %luid
volume balance
?7 #romote overall
health measure
*7 @o assess
precipitating and
causative %actors
87 @o obtain baseline
data
97 @o prevent %luid
overload and monitor
intake and output
37 @o monitor %luid
retention and
evaluate degree o%
e1cess
57 @o determine %luid
retention
+7 $ay indicate
increase in %luid
retention
<7 @o monitor kidney
%unction and %luid
retention
57 =ndicated %luid
retention and edema
?7 @o promote 6ellness
@he patient
shall have
demons4
trated
behaviours
to monitor
%luid status
and reduce
recurrence
o% %luid
e1cess
Assessment Nursing
Diagnosis
Planning Interventions Rationale Evaluation
"bjectives:
=ncrease in
Aab results
()BN,
Creatinine,
uric 2cid
Aevel.
#ulmonary
Congestion
'ypertension
"liguria
2nuria
2ltered
;enal
#er%usion
r-t =ncrease
in )BN,
Creatinine
and Bric
2cid
2%ter 849
hours o%
Nursing
=nterventions
the patient
6ill
demonstrate
participation
in her
recommende
d treatment
program
*7 &stablish
;apport
87 $onitor and
;ecord 0S
97 2ssess
patient:s
general
condition
37 2scertain usual
voiding pattern
57 Note presence,
local intensity
duration o% pain
+7 $onitor )#,
ascertain
patient:s usual
range
<7 #rovide diet
restriction as
indicated, 6hile
providing
adeCuate
calories
57 &ncourage
discussion o%
%eelings
regarding
prognosis or
long term e%%ect
o% discussion
?7 =denti%y
*7 @o get the
cooperation o% the
patient
87 @o obtain
baseline data
97 @o obtain
baseline data
37 @o compare 6ith
current situation
57 $ay indicate pain
on a%%ected organ
+7 D/; may
increase rennin
and raise )#
<7 Calories to meet
body:s need 6hile
restriction o%
protein helps limit
)BN
57 @o decrease
an1iety about
condition and
correct his 6ring
ideas about
condition
?7 @o promote
6ellness and
%urther
progression o%
complication
*,7 Stress or
@he patient shall
have
demonstrated
participation in her
recommended
treatment program
Necessary
changes in
li%estyle and
assist client to
incorporate
disease
management to
2DAs
*,7 2ssess patient
emotional-psyc
hological
%actors
a%%ecting the
current
situation
**7 #romote
overall health
measure
depression may
be increasing the
e%%ect o% an illness
or depression
might be the
result o% being
%orced into
inactivity
**7 @o promote
6ellness
Assessment Nursing
Diagnosis
Planning Intervention Rationale Evaluation
Subjective:
Nahihirapan ako
sa pag ihi as
verbali!ed by the
patient
"bjective:
=ncrease in
lab results
()BN,
Creatinine,
Bric 2cid
Aevel.
2nuria
Brinary
;etention
=mpaired
Brinary
&limination
r-t
glomerular
$al%iltration
2%ter 849
hours o%
nursing
interventions,
the patient 6ill
verbali!e
understanding
o% condition
*7 &stablish
rapport
87 $onitor and
record vital
signs
97 2ssess pt:s
general
condition
37 Determine
clients pattern
o% elimination
57 #alpate
bladder
+7 Determine
client:s usual
daily %luid
intake
<7 &ncourage to
verbali!e
%ear-concerns
57 &mphasi!e the
need to adhere
6ith prescribe
diet
*7 @o get the
cooperation o% the
patient
87 @o obtain baseline
data
97 @o kno6 6hat
problem and
interventions
37 @o assess degree
o% inter%erence
57 @o assess
retention
+7 @o help determine
level o% hydration
<7 "pen e1pression
allo6s client to
deal 6ith %eelings
and begin problem
solving7
57 @o prevent
aggravation o%
disease condition
@he patient shall
have
demonstrated
participation in
his-her
recommended
treatment
program