Ordillas, Romelyn, A.

NCM109a
BSN 2B Group 5
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Excess fluid STG: INDEPENDENT STG:
Data: volume After 8 hours of nursing  Establish rapport.  To gain client’s trust and GOAL MET
None related to intervention, the client’s cooperation. After 8 hours of nursing
decrease in blood pressure will be intervention, the client’s
regulatory within the normal range blood pressure is within the
mechanisms and have a normal fluid normal range and a normal
Objective Data: with balance.  Monitor and record vital  To monitor the progress fluid balance AEB excretion
 Hematuria potential of signs. of the client’s condition. of excessive fluid through
 Proteinuria water as urine and blood pressure of
 Edema evidenced LTG: 110/80mmHg
 Severe by edema, After 3 days of nursing
edema on elevated intervention the client  Assess changes in intake and  To reveal any signs and LTG:
both eyelids blood will have a normal fluid output, headache, urinary symptoms of possible GOAL MET
and legs pressure balance. output, and electrolyte renal failure. After 2 weeks of nursing
 160/92 balance. intervention, the patient will
mmHg demonstrate behaviors,
(blood  Observe behavior changes  Changes in behavior may lifestyle changes to reduce
pressure) related to hypertension. indicate need for safety risk factors of injury AEB
precautions associated avoidance of foods rich in
with seizure activity as a protein, potassium and
result of cerebral sodium and increasing intake
changes. of carbohydrates rich foods.

 Inform parents to report any  Provides for a prompt

weight gain, hematuria with intervention to prevent
decreased urine output, severe renal damage.
complaints of headache and
anorexia.

 Teach parents regarding  Provides nourishment

dietary inclusion and while the disease is being
restriction; provide a list of resolved.
foods to include and avoid
foods that comply with
sodium, potassium, protein
allowances.
 Reinforce to parents the need
for follow-up care and
supervision.
DEPENDENT
 Encourage foods low in  To provide nutrition
sodium, potassium, and
protein and instruct client to
increase intake of food high in
carbohydrates as ordered.
\ oliguria is prolonged.
 Limit fluids as ordered; allow
intake of the amount lost via
urine and insensible losses.
 Administer diuretics as
ordered by the physician.
 To ensure ongoing
monitoring of child for
chronic renal disease or
infection.
during the acute period
with the limitation of
potassium during
oliguria, sodium with the
presence of edema,
protein limitation if
 To avoids additional
fluid retention and edema
in the presence of renal
damage.
 Diuretics are medications
used to increase the
amount of water and salt
expelled from the body
to urine or to excrete
excess fluid.