Assessment Subjective: “ Nagmamanas ang mukha ng anak ako” as vervalized by the patient’s mother Objective: (+) facial edema BP: Temp
: Weight: Urine output:
Nursing Planning Diagnosis Excess Fluid Short term: volume related to After 1 hour failure of of nursing regulatory intervention mechanism the patient (inflammation of will glomerular demonstrate membrane compliance inhibiting with dietary filtration) and fluid evidenced by restrictions weight gain, After an hour edema, and blood of nursing pressure changes intervention the patent’s blood pressure will be within normal limits(systolic of 105 +/- 13) Long term: After 1 week of nursing care and management fluid volume of the patient must stabilize, free
Intervention 1. Assess fluid status a. Daily weight b. Monitor I & O c. Skin turgor and presence of edema d. BP, PR,RR 2. Limit fluid intake to prescribe volume and explain to patient and family the rationale
Rationale Assessment provides baseline and ongoing database for monitoring changes and evaluating interventions .Fluid restriction will be determined on basis of weight, urine output and response to therapy. Understanding promotes patient and family cooperation with fluid restriction
Evaluation Goal met >The patient demonstrated compliance with dietary and fluid restrictions, blood pressure is within the normal limit (110/80mmHg) >Fluid volume is stabilized as manifested by free from signs of edema and vital signs are in normal limits
3. Assist patient to cope with the discomforts resulting from fluid restriction.
Increasing patient comfort promotes compliance with dietary restrictions.
from signs of edema and vital signs within normal limits.
4. or seizures. Teach the mother to report signs of fluid overload. Antihypertensive medication play a key role in treatment of hypertension associated with AGN. These are indications of inadequate control of hypertension and the need to alter therapy.
6. vision changes.
Provides objective data for monitoring. Monitor and record blood pressure as indicated. Elevated levels may indicate non-adherence to the treatment regimen.
5. Administer hypertensive medications as prescribed. headaches.