ASSESSMENT

NURSING
DIAGNOSIS
Subjective:
Fluid
namamanas
volume
ang mga paa at
excess
kamay nya,
related to
tapos ung tiyan
decrease
nya malaki as
Glomerular
verbalized by the filtration
S.O
Rate and
sodium
Objective:
excretion as
With pitting evidence by
edema and
edema of
abdominal
+1
Weight
distention.
gain
Abdominal
distention
Oliguria
Distended
jugular
vein
Changes in
metal
status.

PLANNING
Short Term
After 4-8
hours
of nursing
interventions
, patient will
demonstrate
behaviors to
monitor fluid
status and
reduce
recurrence
of fluid
excess
Long Term
After 3 days
of nursing
intervention
the patient
will manifest
stabilize fluid
volume,
balance I &
O, normal
VS, stable
weight, and

INTERVENTION
INDEPENDENT:
1. Establish
rapport
2. Monitor
vital signs,
Intake and
output, and
weight
daily
3. Change
position of
the client
timely.

4. Restrict
fluid and
sodium
intake if
not

RATIONALE

1.

2.

3.

4.

EVALUATION

Goal partially met:

To gain
The patient
clients
and S.O
trust and
verbalized
cooperati
understanding
on.
and identify
To obtain
some nonbaseline
pharmacologic
data and
al factors to
to monitor
lessen fluid
the
excess.
clients
Demonstrated
status
behaviors to
properly.
monitor fluid
To
status reduce
promote
recurrence
good
of fluid excess
circulation
and to
prevent
presence
of bed
sores or
pressure
ulcer.
To lessen
edema

free from
signs
of edema

contraindic
ated.
5. Raised the
side rails
all the
time.

6. Provide
quite and
restful
environme
nt.

COLLABORATIVE:
7. Administer
medication
s as
prescribe
by the
physician

and fluid
retention.
5. To
promote
clients
safety
and
comfortab
leness
6. To
promote
adequate
rest and
sleep for
as to the
client
recover
energy.
7. To
improves
the
patients
prognosis
and status

ASSESSMENT
Subjective:
nanghihina po
sya tapos
laging ang taas
ng lagnat as
verbalized by
the S.O
Objective:
Low level
of WBC
and other
blood
compone
nts
Pale and
weak in
appearan
ce.
Warm to
touch
Easy
fatigabilit
y
With
temperat
ure of

NURSING
DIAGNOSIS
Ineffective
protection
related to
abnormal blood
profile as
manifested by
elevated body
temperature,
decreased WBC
and other blood
components.

PLANNING

INTERVENTION

After 2 hours of
nursing
intervention,
the patient will
be protect from
infection and
bleeding
hazard that
may contribute
to patients
health
condition and
may
demonstrate
improvements
in vital signs,
laboratory
result and
lessen difficulty
of body
functions.

INDEPENDENT:
1. Monitor
vital signs.
2. Inspect
skin and
mucus
membrane
for any
signs of
bleeding.

3. Implement
measures
to prevent
tissue
injury and
bleeding
such as
using of
soft bristle
toothbrush,
avoiding
sharp
objects and
use of

RATIONALE

EVALUATION

After 2 hours of
1. To obtain
nursing
baseline
intervention,
data
the patient was
2. To be able able to protect
to prevent from infection
risk for
and bleeding
spontane
hazard that
ous and
may contribute
uncontroll to patients
ed
health
bleeding
condition and
3. To avoid
may
risk for
demonstrate
hemorrha
improvements
ge
in vital signs,
following
laboratory
even
result and
minor
lessen difficulty
trauma.
of body
functions.

4. To reduce

38.3 c

cotton
swabs.
4. Limit oral
care to
mouthwash
if indicated
but avoid
mouthwash
with
alcohol.

5. Provided
soft diet if
not
contraindic
ated
6. Avoid
aspirin
containing
antipyretics
.

7. Encourage
proper

risk of
bleeding,
alcohol
has a
drying
effect and
may
irritate
mucus
membran
e
5. It may
reduce
gum
irritation
6. To
prevent
Gastric
bleeding
and
further
decrease
platelet
count.
7. To avoid
cross
contamin
ation and

hygiene
and
handwashi
ng
technique

COLLABORATIVE:
8. Administer
prescribed
medication
s.

to
decrease
occurrenc
e of
infection.
8. To provide
pharmaco
logical
effect to
the client

ASSESSMENT

NURSING
DIAGNOSIS
Subjective:
Knowledge
bigla na lang
deficit related
ba syang
to lack of
nagkaganyan,
information
akala namin
and exposure
hindi malala,
to disease as
kaya ngayon
evidence by
lang namin
requesting of
dinala sa ospital information.
as verbalized by
the S.O
Objective:
Asking for
informatio
n about
the
disease
Lack of
knowledge
about
prevention
and other
nonpharmacol
ogical
actions.

PLANNING
After 1 hour of
nursing
intervention, the
patient and
significant others
will:
Verbalize
understan
ding of
condition/d
isease
process
and
potential
complicati
ons
Verbalize
understan
ding of
therapeuti
c needs.

INTERVENTION
1. Review
disease
process
and
prognosis
and
future
expectati
ons.
2. Fluid and
sodium
restriction
s when
indicated.
3. Discuss
other
nutritional
concerns
such
as regulat
ing
protein
intake
according
to level of
renal

RATIONALE
1. Provides
knowledge
base from
which
patient can
make
informed
choices.
2. To prevent
increase in
fluid excess
and edema
3. Metabolites
that
accumulate
in blood
derive
almost
entirely
from protein
catabolism;
as renal
function
declines,
proteins

EVALUATION
maraming
salamat sa
informasyong
binigay mo sa
amin,
malaking
tulong ito sa
paggaling
nya as
verbalized by
the S.O

 Unable to
follow
instruction
s.
Scratching
of head
and seen
signs of
agreeing.

function

4. Discuss
drug
therapy,
including
use of
calcium
suppleme
nts and
phosphat
e binders
5. Review
measures
to
prevent
bleeding
and
hemorrha
ge
6. Establish
routine
exercise
program
within
limits of

may be
restricted
proportionat
ely
4. Prevents
serious
complicatio
ns and for
the patient
to have
information
about the
drug
therapy.
5. Reduces
risks related
to alteration
of clotting
factors and
decreased
platelet
count.
6. Aids in
maintaining
muscle tone
and joint

individual
ability

flexibility.

ASSESSMENT

NURSING
DIAGNOSIS
Subjective:
Impaired
nahihirapan
Urinary
syang umihi,
Elimination
tapos pakonti
related to
konti lang as
failing
verbalized by the glomerular
S.O
filtration as
evidenced by
Objective:
Impaired
Decreased excretion of
nitrogenous
in Lab
products
results
secondary
( BUN,
Potassium, to Renal Failure
Sodium)
Urinary
retention
Edema
Oliguria

PLANNING
After 2 hours of
nursing
intervention,
the patient will
verbalize
understanding
of condition
and
participate in
measures to
promote good
urinary
elimination

INTERVENTION
1. Assess pts
general
condition

2. Review for
laboratory
test for
changes in
renal
function.
3. Observe for
signs of
infection
4. Emphasize
importance
of having
good
hygiene.
5. Provide
fluids at
frequent

RATIONALE
1. To know
what
problem
and
interventi
ons
should be
prioritize.
2. To assess
for
contributi
ng or
causative
factors.
3. To help in
treating
urinary
alteration
s
4. To
promote
wellness
and to
decrease
occurrenc
e of
infection

EVALUATION
After 2 hours of
nursing
intervention,
the patient was
able to
verbalize
understanding
of condition
and participate
in measures to
promote good
urinary
elimination

intervals.

6. Establish
routine
exercise
program
within
limits of
individual
ability.
7. Fluid and
sodium
restrictions
when
indicated.
8. Administer
medication
s as
prescribe
by the
physician

5. To help
maintain
renal
function,
hydration
and to
avoid
formation
of urinary
stone
6. to
promote
good
circulatio
n and
maintaini
ng
muscle
tone
7. To avoid
urinary
retention
that aids
in
difficulty
of
urination.
8. To

improves
the
patients
prognosis
and
status

ASSESSMENT
Subjective:
lagi lang
syang
nakahiga,
tapos ang nipis
na ng balat
nya, baka
biglang
magkasugat
as verbalized
by the S.O
Objective:
Body
weaknes
s
Limited
ROM
Edema
Seen
patient
always
lying on
bed
With long
dirty
nails in

NURSING
DIAGNOSIS
Risk for
impaired
skin
integrity
related to
limited
mobility
and activity
secondary
to ascites
and edema.

PLANNING
After 3 hours of
nursing
intervention, the
patient will
maintain intact
skin and
demonstrate
behaviors/techni
ques to prevent
skin
breakdown/injury
.

INTERVENTION
1. Inspect skin
for changes
in color,
turgor,
vascularity

2. Change
position
frequently;
move
patient
carefully

3. Provide
soothing
skin care.
Restrict use
of soaps.
4. Keep linens
dry, wrinklefree

RATIONALE
1. Indicates
areas of
poor
circulation
or
breakdown
that may
lead to
decubitus
formation
and
infection
2. Decreases
pressure
on
edematous
, poorly
perfuse
tissues to
reduce
ischemia.
3. To
decrease
itching and
drying of
the skin.
4. Reduces

EVALUATION
After 3 hours of
nursing
intervention, the
patient was able
tp maintain
intact skin and
demonstrate
behaviors/techni
ques to prevent
skin
breakdown/injury
.

hands
and feet
With
reddened
, thin and
shiny
skin on
abdomin
al area.

5. Suggest
wearing
loose-fitting
cotton
garments.
5.

6. Give
diversional
activities.

7. Persuade
ambulation
if patient is
able.
8. Encouraged
to do some
range of
motion
exercises.

6.

7.

8.

dermal
irritation
and risk of
skin
breakdown
.
Prevents
direct
dermal
irritation
and
promotes
evaporatio
n of
moisture
on the
skin.
Helps in
refocusing
attention,
decreasing
tendency
to scratch.
To promote
blood
circulation.
Aids in
maintainin
g muscle

tone and
joint
flexibility.

I.

NURSING PROCESS
A. LONGTERM OBJECTIVE
The nursing plan aims to return the patient to its normal body feeling. It
also aims to restore the healthy body of the patient. And to ensure the
physiological well-being of the patient by providing patient and family
teachings through addressing emotional and psychosocial needs .
B. PRIORITIZED LIST NURSING PROBLEM

PROBLEM

RANKING

Fluid
volume
excess
related
to
decrease
Glomerular
filtration
Rate
and
sodium
excretion
as
evidence
by
edema
and
abdominal
distention.

Impaired Urinary
Elimination
related to failing
glomerular
filtration as
evidenced by
Impaired
excretion of
nitrogenous
products
secondary
to Renal Failure
Ineffective
protection

JUSTIFICATION

Fluid volume excess

must be prioritized first
because this will aid to
different complications.
If this will treated
immediately or if given
with appropriate
intervention, there is a
high possibility of the
patient to go back to its
normal body
mechanism.
This must be prioritized
second because
impaired urinary
elimination was done by
excess fluids in the
body. This will resolve if
the first diagnosis
treated.

It goes as third to
prioritize because

related to
abnormal blood
profile as
manifested by
elevated body
temperature,
decreased WBC
and other blood
components.
Risk for
impaired skin
integrity related
to limited
mobility and
activity
secondary to
ascites and
edema.
Knowledge
deficit related to
lack of
information and
exposure to
disease as
evidence by
requesting of
information.

ineffective protection
happened if there is
infection in our body.
And this is due to high
level of fluids that
retains in circulation.
This problem can
subside if the first to be
treated was the fluid
excess.
This is prioritized as a
fourth because it was
just a risk and has a
high possibility to
control. This will not
become the patients
problem if good
intervention will give.
This should be the last
to prioritized because it
will not give much
problem in the case of
the patient since the
disease was there. Right
health teaching needs
to be given to the
patient. Information to
the patient was a great
source to reduce the
other complications and
can prevent occurrence
of other diseases.