Assessment Nursing Diagnosis Goals and Objectives Nursing Interventions Rationale Expected Outcome

Subjective: O Excess fluid volume Short Term Goals: 1. Obtain complete To have baseline data Goal is met.
Objective: related to accumulation After 8 hours of physical on the progress of fluid
- facial edema of fluids in the body nursing assessment. elimination through The patient have
secondary to acute interventions, the physical appearance. sustained minimum
glomerulonephritis patient will be able To have a measurable urine output of
to have an increased account on the fluid 30mL per hour and
urine output of 70-80 2. Monitor daily elimination. manifest lesser
ml for the next 6 weight. To know progressing edema
hours. condition via
glomerular filtration.
Long Term Goals: 3. Monitor fluid intake To know progression
Client will have a and output every 4 of hypertension and
sustained minimum hours. basis for further
urine output of 20 ml nursing intervention or
per hour and referral.
manifest lesser 4. Monitor BP and PR To know for possible
edema (+) every hour. progression in the
lungs.
To know the extent of
protein loss which led
to edema.
5. Assess for
adventitious breath Helps increase blood
sounds. and fluid circulation.

6. Monitor laboratory Reinforces awareness

values especially for on its effect on fluid
the protein level in the excretion.
urine.
Helps prevent skin
7. Encourage breakdown and further
ambulation and infection arising from
non strenuous the skin.
exercises. For client cooperation
8. Teach on the even in the absence of
 importance of any medical
elevating extremities practitioner.
when Helps excrete excess
at rest. fluids through
9. Encouraged to pharmacological
maintain reaction.
clean and moist skin.

10. Encouraged to
stick on dietary and
fluid restrictions.

11. Administer
diuretics as ordered.
Subjective: O Ineffective Breathing Short Term Goals: 1. Position client in to promote proper lung Goal is met
Objective: Pattern related to After 15minutes of Semi-fowler’s expansion.
- increased RR of accumulation of fluid thorough nursing position. The patient
26 cpm in the peritoneal cavity intervention, the 2. Assist client during to promote circulation maintained normal
client will be able to: ambulation. rate of respiration.
a. Improve his 3. Encourage rest to conserve energy
respiration from 26 periods from client consumption.
cpm to 20 cpm. and avoid exertion on
b. Demonstrate unnecessary activities.
responsiveness by 4. Listen to the client’s
answering questions. verbalization about the
c. verbalize the problem it will encourage
activity intolerance verbalization of
Dependent: feelings.
Long Term Goals: 1. Administer Packed
After 2-3 days of RBC 450ml for 4 – 6
thorough nursing hours, as ordered.
intervention, the
client will be able to: to enhance oxygen
a. achieve and carrying capacity of the
maintain normal body.
range of respiration
 (15 – 22cpm)
Subjective: O Risk for infection Short Term Goals: 1. Assess temperature, Reveals persistence Goal is met
Objective: O related to chronic After 8 hours of chills, sore throat, of streptococcal
disease nursing cough (presence infection. The patient should
interventions, the or recurrence). have not
patient will have a 2. Obtain throat experienced a sore
negative throat culture for analysis Identifies throat.
culture and sensitivities. streptococcal 
microorganism and
Long Term Goals: sensitivity to
After 3-4 days of specific antibiotic
nursing 3. Administer therapy.
interventions, the antibiotic therapy Destroys microbial
patient will not to the child and to agents by preventing
experience a sore family members cell wall synthesis and
throat if ordered. prevents transmission
to family members.
Prevents transmission
4. Provide proper of microorganisms to
disposal of used others or reinfection.
tissues and articles. Promotes parental
understanding and
prevents the
5. Instruct parents development of super-
about the importance infection.
of taking the full
course of antibiotic Prevents transfer of
therapy. disease.
6. Instruct child and
family to
do handwashing after
sneezing/ coughing
and to properly
disposed used tissues. Avoids respiratory
7. Instruct parents to infections in the
avoid exposure of the susceptible child.
 child to others with an
existing upper
respiratory infection.
8. Instruct parents to
notify health care Indicates infection and
provider provides for early
if fever, cough, sore intervention.
throat is present.

11-15-2020 F: Fluid Volume Excess D: received pt sitting on bed conscious and coherent with an IVF bottle of NaCl 0.9% at a level
6-2 related to accumulation of of 500 cc running as KVO infusing well on the right hand
fluids in the body A: 1. Obtained complete physical assessment.
secondary to acute 2. Monitored daily weight.
glomerulonephritis 3. Monitored fluid intake and output every 4 hours.
4. Monitored BP and PR every hour.
5. Assessed for adventitious breath sounds.
6. Monitored laboratory values especially for the protein level in the urine.
7. Encouraged ambulation and non-strenuous exercises.
8. Taught on the importance of elevating extremities when at rest.
9. Encouraged to maintain clean and moist skin.
10. Encouraged to stick on dietary and fluid restrictions.
11. Administered diuretics as ordered.
R: The patient have sustained minimum urine output of 30mL per hour and manifested
decreased facial edema.