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NURSING CARE PLAN ASSESSMENT SUBJECTIVE: “Namamanas ang kanang binti ng anak ko” (My son has
a massive edema on his lower right leg) as
DIAGNOSIS Excess fluid volume related to compromised regulatory mechanism with changes in hydrostatic or oncotic vascular pressure and increased activation of the renninangiotensinaldosterone system.
INFERENCE Nephrotic syndrome is a clinical disorder of unknown cause characterized by proteinuria, hypoalbuminemia , edema, and hyperlipidemia. This conditions result from excessive leakage of plasma proteins into the urine because of impairment of the glomerular capillary membrane. •
RATIONALE Accurate Intake and output is necessary for determining renal function and fluid replacement needs and reducing risk of fluid overload. Measures the kidney’s ability to concentrate urine. Daily body weight is the best monitor of fluid status. A weight gain of more than 0.5 kg/day suggest fluid retention. Edema occurs primarily in dependent tissues of the body. It will serve as parameter the •
EVALUATION After 8 hours of nursing interventions, the patient was able to display stable weight, vital signs within patient’s normal range, and nearly absence of edema.
verbalized by the mother. OBJECTIVE: • • • • Edema Weight gain Changes in vital signs V/S taken as follows: T: 37.3 P: 85 R: 21
INDEPENDENT: After 8 hours • Record accurate of nursing intake and interventions, output of the the patient will patient. display stable weight, vital signs within patient’s normal range, and nearly absence of edema. • Monitor urine specific gravity.
Weigh daily at same time of the day, on same scale, with same equipment and clothing.
Assess skin, face, dependent areas of edema.
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severity of fluid excess. • Monitor heart rate and blood pressure. • Tachycardia and hypertension can occur because of failure of the kidneys to excrete urine. May reflect fluid shifts and electrolyte imbalances.
Assess level of consciousness; investigate changes in mentation, presence of restlessness.
COLLABORATIVE: • Monitor laboratory and diagnostic studies.
Provide assessment of the progression and management of the dysfunction. To promote adequate urine volume that aids in prevention of further edema.
Administer diuretics as prescribed.