PATIENT: TSG JUMAWIL, ZOSIMO DIAGNOSIS: CRF secondary to CPN

ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC RATIONALE OBJECTIVES of CARE NURSING INTERVENTIOS RATIONALE EVALUATION

S: ------------------ Excess fluid volume Renal infection Within 7 hours of nursing *elevate edematous *to reduce tissue After 7 hours of nursing
related to CRF secondary interventions, the extremities, change pressure and risk for skin interventions, the
O: *edema to CPN. patients excess fluid position frequently. breakdown. patient’s excess fluid
*oliguria Inflammation volume will be decreased volume was decreased as
*distended jugular as evidenced by decrease *stress need for mobility *to reduce risk for tissue evidenced by decrease in
neck vein in edema of pt. injury. edema of pt.
Scar formation
*weigh patient on *to have baseline data GOAL MET!!!
regular schedule. for effectiveness of the
Renal tubules treatment.
obstruction
*monitor rate of fluid *to prevent
intake/infusion in 24 peaks/valleys in fluid
Decrease blood flow hour period.. level.

*restrict sodium and

Renal failure fluid intake as indicated.
MARLON C. SOLANOY
*assess neuromuscular *to evaluate for GROUP 49
Decrease output reflexes. presence of electrolyte
imbalance.

Excess fluid volume *observe skin and *ulceration may develop.

mucous membranes.

*administer diuretics as
ordered.