NURSING CARE PLAN

NURSING MAY BE POSSIBLY EVIDENCE DESIRED NURSING RATIONALE

DIAGNOSIS RELATED TO BY OUTCOMES INTERVENTIONS
o Pitting edema. Patient’s Strictly monitor and Accurate
Decreased edema will be record intake and measurement
kidney Periorbital and facial decreased. output. determines fluid
function puffiness in the balance.
morning and Patients will
Fluid dependent in the achieve ideal Amount off
accumulation evening. body weight allowed fluid
without Advised to limit intake is
Abdominal ascites. excess fluids. fluid intake as determined
Excess Fluid ordered. based on the
Volume Scrotal or labial patient’s
edema. weight, urine
output and
Edema of mucous response to
membranes of treatment
intestines.

Anasarca

Slow weight gain

Decreased urine
output

Altered electrolytes.

NURSING MAY BE POSSIBLY DESIRED NURSING RATIONALE

DIAGNOSIS RELATED TO EVDENCE BY OUTCOMES INTERVENTION
Anorexia Encourage high A high potassium
potassium, low-fat, diet maintains
Weight loss low sodium diet therapeutic serum
with moderate potassium level,
Edema of the amounts of especially if the
intestinal tract protein. patient is receiving
Imbalanced Inability to affects the The patient a potassium-
Nutrition: Less ingest and absorption will consume a wasting diuretic. A
than Body digest foods nutritionally low-sodium helps
Requirements and absorb Rejection of balanced diet prevent or
nutrients. low salt diet decrease fluid
retention. Protein
intake is needed to
Loss of protein
compensate for
(negative
protein loss.
nitrogen
balance)
Monitor patient’s Nurses need to
weight daily weight patient to
monitor fluid and
nutritional status

NURSING MAY BE POSSIBLY DESIRED NURSING RATIONALE

 DIAGNOSIS RELATED EVIDENCED OUTCOMES INTERVENTION
TO BY
Easily Reinforce bed Prevents energy
fatigued with rest during the expenditure when edema
any activity Patients will most acute stage. is severe
Fatigue Discomfort alternate
Extreme activity with Assess extent of Reveals information
edema rest periods. fatigue, regarding fatigue and
weakness, degree tendency of lying in the
Lethargy of edema and prone position and not
difficult moving or changing
movement or position.
activity in bed

NURSING MAY BE POSSIBLY DESIRED NURSING RATIONALE

DIAGNOSIS RELATED EVIDENCED BY OUTCOMES INTERVENTION
TO
Lack of Expressed Assess knowledge of Provides information
exposure to need for disease, signs and about education needs for
information information symptoms of follow-up care
about the about the relapse, dietary and
disease disease, drug activity aspects of
administration, Patients care, medication
follow-up care verbalize administration and
and understanding side effects,
Deficient procedures. of cause and monitoring urine and
Knowledge treatment for vital signs
Anxiety illness Promotes compliance of
associated with Educate about the proper medication
relapse of administration of administration and what
disease medications can be expected from drug
including reversible therapy
side effects of
steroid and
immunosuppressive
when discontinued
abruptly, that they
must be stopped
gradually to avoid
complication

NURSING MAY BE RELATED DESIRED NURSING RATIONALE

DIAGNOSIS TO OUTCOMES INTERVENTION
Inadequate The patient’s Explain the Will help the nurse plan needed
defences of the body possible signs and interventions to avoid relapse
body secondary temperature symptoms of and complications
to nephrotic will remain at infection and
syndrome its appropriate advise to report as
levels soon as possible if
the sign and
Risk for Infection The breath symptoms are
sounds of the present
patient will be
ausculatated Provide and Medications will help in
clear administer preventing and treating
bilaterally medication as infections and will help in
needed and as preventing possible
The patient’s prescribed by the complications
urine will doctor and
appear clear monitor the
and without a patient after
foul – smelling medication
odor administration