B.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Imbalanced Renal failure 9/28/2022  Encourage client to  To stimulate 9/28/2022
“Basissit lang NUTRITION: less ↓ 7-3 shift choose foods or have appetite. 7-3 shift
kankanen na, tallo lang than body ↓ blood flow to the kidneys 8 Am family member bring 12:00 pm
nga kutsara.” as requirements r/t ↓ After 4 hours of foods that seem After 4 hours of nursing
verbalized by the Insufficient dietary ↓perfusion in kidney nursing intervention appealing intervention the patient were
patient´s mother. intake aeb food intake ↓ the patient will be able to:
less than ↓ urinary output able to:  To enhance food  Displayed normalization of
 Use flavoring agents
Objective: recommended daily ↓  Display satisfaction and laboratory values and be
 Food intake less allowances, BW: 15.6 water retention normalization of stimulate appetite. free of signs of malnutrition
 Limit fiber or bulk
than kgs., and loss of ↓ laboratory values  It may lead to early as reflected in Defining
recommended appetite Fluid volume excess and be free of Characteristics.
 Promote pleasant, satiety.
daily allowances signs of  Verbalized understanding
relaxing environment,
 Loss of appetite malnutrition as  To enhance intake. of causative factors when
including
 BW: 15.6 kgs. reflected in known and necessary
socialization when
Defining interventions.
possible
Characteristics.
 Assist with or provide  Poor oral hygiene  Demonstrated behaviors
 Verbalize
oral care before and causes oral and lifestyle changes to
understanding of discomfort, pain, and regain and/or maintain
after meals and at
causative factors effect on chewing appropriate weight.
bedtime.
when known and and swallowing that GOAL MET
necessary affect nutritional
interventions.  Emphasize intake.
 Demonstrate importance of well-
behaviors and balanced, nutritious
lifestyle changes intake. Provide  Essential for good
to regain and/or information regarding health and nutrition.
maintain individual nutritional
https://nursestudy.net/
excess-fluid-volume- appropriate needs and ways to
nursing-diagnosis/ weight. meet these needs
 within financial
constraints

COLLABORATION  To set nutritional

 Collaborate with goals when client has
interdisciplinary team specific dietary
needs, malnutrition is
profound, or long-
term feeding
problems exist.

ASSESSMENT DIAGNOSIS NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for deficient fluid Biologic, psychologic, 9/27/2022  Limit patient fluid  To limit the fluid 9/27/2022
“Mamin siyam suna volume r/t active fluid economic factors 12-7 shift intake to 200 ml per in the body. 12-7 shift
nga imisbo.” as volume loss aeb ↓ 3:00 pm shift. 5:00 pm
verbalized by the excessive urinating. Impair a person’s ability to After 2 hours of  Compare current fluid  To be aware of After 2 hours of nursing
patient´s mother. ingest or digest food/ absorb nursing intervention intake to fluid goal. the changes in intervention the patient were
nutrients the patient will be Monitor intake and intake or output, able to:
Objective: ↓ able to:  Identified individual risk
output (I&O) balance as well as
 Excessive Imbalanced Nutrition  Identify individual factors and appropriate
insensible losses
urination (less than body requirements\ risk factors and interventions.
to ensure an
 300 mL fluid appropriate  Maintained fluid volume at
accurate picture of
intake (limit 200 interventions. a functional level as
 Discuss individual fluid status.
mL per shift).  Maintain fluid evidenced by individually
risk factors, potential  To reduce risk of
volume at a adequate urinary output with
problems, and injury and
functional level as normal specific gravity,
specific interventions dehydration
evidenced by stable vital signs, moist
individually mucous membranes, good
 Review the client’s
adequate urinary  To identify skin turgor, and prompt
medications,
output with medications that capillary refi ll.
including
normal specific can alter fluid and  Demonstrated behaviors or
prescription, over-the-
gravity, stable electrolyte lifestyle changes to prevent
counter drugs, herbs,
vital signs, moist development of fluid
 mucous and nutritional balance. volume deficit.
membranes, good supplements, GOAL MET.
skin turgor, and  Review laboratory  To evaluate fluid
prompt capillary data and electrolyte
refi ll. status.
 Demonstrate
behaviors or  Determine individual  To increase the
lifestyle changes fluid needs and client’s daily fluid
to prevent establish replacement intake.
development of over 24 hr
fluid volume
deficit.
DEPENDENT
 Administer  Helps your body
Furosemide as get rid of excess
prescribed. water.

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glomerulonephritis-agn-
nursing-care-plan/