UNIVERSITY OF NUEVA CACERES

Nursing Care Plan

Form
College of Nursing

Name:Acob & Casillan Year & Section: 2B Area: City Health Office 1 Schedule: Mon to Wed., 12:00 - 5:00 pm CI: Noel Sta. Isabel, RN

ASSESSMENT N-DIAGNOSIS RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Data: Risk for Imbalanced Kidney failure Short Term: Independent: Short term: Goal
- Nutrition: Less Than leads to metabolic After 8 hours of nursing 1. Monitor the patient’s vital 1. This will be used as met
Body Requirements r/t changes, requiring interventions, the patient signs. the baseline data for
dietary restrictions and 2. Conduct a the patient’s
Objective Data: dietary restrictions will be able to: After 8 hours of
metabolic alterations comprehensive condition at the time
(+) weakness of the s/t kidney failure like reduced nutritional assessment being. nursing interventions,
muscles protein and altered a. ensure that the including dietary history, 2. Assessing the the patient was able
(c) bilateral pedal edema fluid intake. These patient meets nutritional status, weight patient's nutritional ensure that the
(+) altered skin turgor restrictions can their nutritional trends, laboratory values. status aids in the patient received
(+) dry skin, dry mucosa cause malnutrition, needs despite 3. Monitor the patient’s identification of risk their nutritional
(+) fatigue making the risk for dietary daily nutritional intake, factors contributing needs regardless of
including calorie, protein, to imbalanced
imbalanced restrictions and dietary limitations
fluid, and micronutrient nutrition and directs
Vital Signs: nutrition directly metabolic consumption, using food the formulation of a and metabolic
BP: 150/100 related to kidney alterations diaries and meal logos. customized care change; maintained
HR: 140 bpm failure. b. maintain 4. Encourage the patient to plan. appropriate hydration
RR: 14 bpm eat small, frequent meals 3. Regular nutritional
adequate while sticking to fluid
O2 Sat: 93% throughout the day to intake monitoring
hydration while limitations to avoid
adhering to fluid improve appetite, aids in determining fluid overload; and
Diagnostics: prevent overloading adherence to dietary
restrictions to verbalized
kidneys with a large requirements,
Creatinine: 7.1 mg/dl prevent fluid meal, and maintain identifying areas for awareness of dietary
BUN: 9.0 mg/dl overload steady energy. improvement or constraints,
c. verbalize 5. Monitor laboratory values modification, and nutrient-rich food
understanding r/t nutrition: serum assessing the choices, and ways to
about dietary albumin. hemoglobin, long-term impact on improve nutritional
electrolytes. nutritional status.
restrictions and intake
4. Small, frequent
 nutrient rich food meals are easier to
choices & digest, reduce Long Term: Goal
strategies to gastrointestinal met
distress, and can aid
optimize After 1 week of
in nutrient absorption
nutritional intake in patients with nursing interventions,
kidney failure and the patient was able
imbalanced nutrition. to ensure that the
Long Term: 5. Regular laboratory patient received
After 1 week of nursing value monitoring their nutritional
interventions, the patient aids in the early needs regardless of
detection of
will be able to: dietary limitations
nutritional
a. ensure that the deficiencies and the and metabolic
patient receives implementation of change; maintained
their nutritional prompt measures, appropriate hydration
needs such as while sticking to fluid
regardless of supplementation or limitations to avoid
dietary dietary changes, to fluid overload; and
avoid difficulties
limitations and verbalized
associated with
metabolic imbalanced nutrition. awareness of dietary
change constraints,
b. maintain Dependent; Dependent: nutrient-rich food
appropriate 1. Administer nutritional 1. Nutritional choices, and ways to
hydration while supplements such as supplements, such improve nutritional
high-calorie, high protein as high-calorie,
sticking to fluid intake
or vitamin/mineral high-protein
limitations to supplements formulae or
avoid fluid vitamin/mineral
overload supplements, may
c. verbalize be administered to
awareness of fulfill the patient's
dietary increased nutritional
requirements and
constraints,
avoid deficiencies
nutrient-rich food that are common in
choices, and kidney failure
ways to improve patients due to food
nutritional intake limitations and
changed
metabolism.

2
Collaborative:
1. Consult with a dietician
regarding nutrition.
2. Provide emotional
support for the client and
the patient’s family.
Collaborative:
1. A registered dietitian
can evaluate the
patient's nutritional
status, create an
individualized
nutrition plan based
on dietary
restrictions (e.g., low
protein, low
potassium), and
provide ongoing
dietary counseling to
ensure adequate
nutrient intake while
managing metabolic
changes associated
with kidney failure.
2. Patients with renal
failure and
decreased cardiac
output may
experience anxiety,
fear, or stress
related to their
condition and
treatment. Offering
emotional support,
education about the
disease process,
medications, and
self-care measures
can improve patient
understanding,
compliance, and
overall well-being.