Sweet Glomerulus: A Case of Diabetic Nephropathy

Chapter 8
NURSING CARE PLANS

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Impaired tissue After 8 hours of Independent:
Ang bilis ko na perfussion related to health teaching and a. Assess energy a. Decreases oxygen a. The patient
hapuin pero na decrease hemoglobin medical management level and activity demand. verbalized, Hindi na
relieved naman pag level as evidenced by patient should be tolerance. ko masyado nag
nag rest ako, elevated creatinine able to understanding b. Encourage kikilos hanggat maari
para hindi na din ako
sasalinan nga daw level 7.3 mg/dl, on how to prevent adequate rest.
hapuin.
ako ng dugo kasi BUN: 84 mg/dl. the occurances of
bagsak hemoglibin difficuty of breathing Dependent:
ko sira na daw kasi brought about by c. Maintain to b.To maintain
b.Increased in
ang bato ko decrease hemoglobin oxygen support via equilibrium of
Oxygen saturation
level face mask at 8 LPM oxygen needs and
from 90% to 98%
Objective: d. Blood transfusion demand and
Hemoglobin: 78 g/l of 3 units Packed improved respiratory
Tachycardia:110 bpm RBC. (done during function.
Respiratory rate: 27 hemodialysis)
Creatinine: 7.3 mg/dl
c. Repeat of
BUN: 84mg/dl e. Epoetin alfa 4000 c. Stimulate bone
hemoglobin level
O2 sat: 90 % IU SubQ injection 2 marrow release of
from 78 mg/dl to 102
times a week. RBC.
(6 hours post B.T)
Collaborative:

f. Instruct patient to
ask for assistance
during ambulation/
transfer.

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 Sweet Glomerulus: A Case of Diabetic Nephropathy

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Fluid volume After an hour of Independent:
Sabi ng anak ko excess related health a. Assess pedal area a. Edema occurs in a. Absence of edema in
namamanas ung paa ko to teachings, the for edema. dependent tissues of pedal area.
hindi ko naman kita pero compromised patient should b. Administer/restri body(e.g. hands, feet,
pag sa umaga pag kinapa regulatory be able to ct fluids as face) b. Clear lung sounds
ko medyo manas nga sa mechanism verbalize his ordered. b. To minimize the through auscultation.
magkabilang paa ko , as (renal failure) understanding occurrence of fluid
verbalized by the patient. as evidenced regarding fluid Dependent: excess.
by restrictions and c. Monitor weight c. To evaluate the c. The patient verbalized,
Objective: Grade 1 necessary pre and post amount of fluid Sabi ni dra, limit
Pre-weight=83 edema on measures to dialysis. removed. lamang daw talaga sa
kg both legs, prevent fluid d. Dialysis tubig.
Significant Fine rales on excess. treatment twice a d. To determine the d. The patient follows his
weight gain from both basal week. presence of fluid regular schedule every
day 1 of area of lungs, After 4 hours of e. Auscultate lung accumulation in the Wednesday and
admission to day increase hemodialysis sounds pre and lungs Thursday of dialysis
3 of confinement creatinine treatment, the post dialysis. e. The patient verbalized,
= 2.5 kg (day 3 level at 7.3 patient should Konti lamang naman
weight 85.5) mg/dl. be free from Collaborative: e. Facilitates reduction ang iniinom ko gaya
Facial edema any signs of f. Instruct patient of extracellular ng sabi ni Dra.
fluid overload. regarding fluid volume. f. The patient
Crackles on both
restrictions as verbalized,Tinatry ko
basal area of
appropriate. f. To promote fluid pa din maglakad-lakad
lungs
g. Instruct the mobilization in the tuwing umaga
Oliguria body and to prevent hanggat kaya ko.
patient to do
(<400ml/day) fluid accumulation in
some exercise
Hemodialysis 2 regularly as long extracellular space.
times a week as the body can.

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 Sweet Glomerulus: A Case of Diabetic Nephropathy

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Altered After an hour of Independent:
Sobrang nahirapan ako sensory health teachings, a. Listen and a. To encourage a. The patient tells a
nung nawala ang perception the patient will respect clients verbalization of story how his
paningin ko, liwanag na (visual) demonstrate expression of feelings. family helps him
lang ang nakikita ko related to behaviors to dependency. in daily activities.
pero sobrang labo na microvascular prevent accidents b. Re-orient to time, b. Enhances patients b. The patient
nang paningin ko, destruction that can result place, and staff well-being and verbalized, May
kelangan ko lagi ng secondary to due to visual and events as sense of apat na oras pa ko
kasama kapag Diabetes impairment. necessary. importance. Nurse ron para
maglalakad ako, as Mellitus. matulog.
verbalized by the c. Explain c. To promote c. The patient
patient. procedures/ participation. verbalized, Sige,
expected sabihin mo kapag
Objective: sensations and mag start na ng
Bilateral outcomes. dialysis ah,para
blurring of alam ko na
visions nababwasan na
Dependency on ung apat na oras
significant Collaborative: ng dialysis .
others d. Provide rest d. To conserve d. Seen patient
Poor periods. energy. resting and
concentration sleeping for
e. Instruct the e. To aid in almost 3-4 hours
relatives not to maintaining during treatment.
leave the client. balance. e. Seen patients
f. Instruct patient to relative always on
ask for assistance f. To prevent falls. his side.
during f. Seen patient
ambulation/ transferring with
transfer. assistance of his
g. Use of cane. g. Provide stable son.
gait.
g. Seen patient
walking with the
use of cane.

33
 Sweet Glomerulus: A Case of Diabetic Nephropathy

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: High risk for After an hour of Independent:
Sobrang nag- impaired skin health teachings on a. Instruct to wear a. To prevent any foot a. Seen patient wearing
iingat ako integrity related preventive protective socks. skin breakdown. socks.
magkasugat, kasi to altered measures, the patient b. Skin breakdown can b. No actual additional
sabi ng doctor, sensation will be able to Dependent: occur quickly with skin breakdown
matagal nga daw secondary to verbalize b. Inspect skin surface potential for seen.
gumaling, as disease process understanding to in the lower extremities infection and
verbalized by the as evidenced prevent skin c. Monitor and necrosis.
patient. by high glucose breakdown and will maintain glucose levels at c. range as often as c. Patient verbalized,
levels of 230 be able to normal range possible will Nagtetake ako ng
Objective: mg/dl and demonstrate (hypoglycemic agents). dramatically reduce Januvia isang beses
FBS= 230 lesions noted preventive the risk of serious sa isang araw.
mg/dl on lower measures. Collaborative: complications of
Lesions extremities. (evaluation of this diabetes.
noted on plan is done on the
lower last day of d. Limit drinking d. Drinking caffeine d. Patient verbalized,
extremitie confinement) beverages which contains beverages can Minsan na lamang
s. caffeine. constrict blood ako uminom ng
vessels and may kape.
contribute to
circulation
problems.
e. Check feet daily and e. Most problems for e. Patient verbalized,
immediately care for small diabetes begins with Sa tuwing
cuts or blister. small sores on the magkakasugat ako,
skin like blisters. ginagamot ko kagad
para hindi na lumala
pa.

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