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NURSING CARE PLAN

NCM 109 RLE CLINICAL

Wednesday 7:00 AM – 12:00 PM

Submitted by:
REGALA, BIANCA YSABELLE M.
BSN II – B
Group 3
DIARRHEA
Name: Akihiro Leonel Juarez Age: 8 years old Sex: Male

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective data: Diarrhea r/t Short Term: Independent: Independent: Short Term:
infectious
“Apat na beses na siya -- After 2-3 hours of 1.) Auscultate the abdomen. 1.) For presence. Location -- After 2-3 hours of nursing
processes.
dumumi ngayong araw. nursing and characteristics of bowel interventions, the patient’s
Samantalang kahapon interventions, the sounds. mother gained knowledge
mga tatlong beses. patient’s mother will about diarrhea and
Madalas din kung sumuka gain knowledge 2.) Discuss to the mother the verbalized understanding of
siya.” As verbalized by the about diarrhea. 2.) For the education of the causative factors of diarrhea
different causative factors
mother patient’s mother. and rationale for treatment
and rationale for treatment
regimen. regimen.
Expected Outcome:
Verbalize
Long Term:
Objective data: understanding of 3.) Restrict solid food intake. 3.) To allow for bowel rest
causative factor. and reduce intestinal -- After 1-2 days of nursing
workload. interventions, the patient
-Loosed bowel movement has been free of diarrhea as
with yellowish watery Verbalize the evidenced by re-established
stool minimum of thrice a rationale for and maintained normal
day. treatment regimen. 4.) Provide for changes in 4.) To allow foods that bowel movement, reduced
dietary intake. precipitates diarrhea. in frequency of stools and
-Increase bowel sounds/
peristalsis stool returned to its normal
Long Term: consistency.
-Nausea and Vomiting 5.) Limit caffeine, high fiber 5.) To prevent gastric
-- After 1-2 days of foods and fatty foods. irritation.
-Abdominal cramping nursing
interventions, the
-Vital signs taken as
follows:
 patient will be free of
 BP: 110/60 mmHg Dependent: Dependent:
diarrhea.
 PR: 90 bpm 1.) Administer anti-diarrheal 1.) To decrease GI motility
 RR: 22 cpm medications, as indicated. and minimize fluid losses.
 Temperature: 35.7 ◦ Expected Outcome:
-- Re-establish and
2.) Administer medications, 2.) To treat infectious
maintain normal
as ordered. process, decrease motility
bowel movement.
and/or absorb water.

-- Reduction in
frequency of stools.

-- Return of the stool

to the normal
consistency.
Name: Sebastian Vincent Camero Age: 8 years old Sex: Male

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Diarrhea related After 8 hours of Independent: After 8 hours of nursing

to ingestion of nursing care, client care, the goal is partially met
-Observe and record the -It could help determine the
suspected will be able to re- as evidenced by reduction in
frequency, amount, time, causative factor and the need
“Sumasakit po ang tiyan contaminated establish and frequency of passing of stool
and characteristics of stool for additional hydration
niya at madalas po siyang food. maintain normal to 3 from previous of
and for any presence of replacement.
dumudumi sa banyo.” – as bowel functioning. precipitating factors. 6.
verbalized by the mother.

-Provide a quite and non -Stress can trigger frequent

Objective: passing of stools; with these
stimulating environment
and teach client of measures, stress could be
relaxation techniques to avoided or relieved.
 Passed loose watery
decrease stress.
stools for 5 times
already .
 Frequent flatulence -Emphasize to increase fluid - Rehydration is the top
as claimed. intake especially those priority in diarrhea.
 Presence of containing with electrolytes,
abdominal cramps i.e. ORS.
Ate “isaw” (grilled
chicken intestine).
day prior to onset of - Educate on how to prepare -This could prevent
symptoms food properly and the outbreaks and spread of
 Vital signs taken as importance of good food infectious diseases
follows: sanitation practices and transmitted through fecal-
BP= 110/60mmHg hand washing. oral route.
PR= 87bpm
RR= 20cpm
 Temperature= 36.7⁰
 Skin warm and moist
 Good skin turgor -Educate on what to do in -Discharge health teaching
and capillary refill case diarrhea may happen may be necessary to provide
again or with family adequate information on
members to prevent how to prevent and manage
dehydration. diarrhea at home.

Dependent:
-Restrict foods as indicated - These foods can add more
like foods containing irritation to the stomach.
caffeine, too much oil, fiber,
milk, and fruits.

- Start venoclysis and -Hydrating the client helps

intravenous replacement as replace the fluid and
indicated. electrolyte he loose from
diarrhea.

-Administer antidiarrheal -These agents could help halt

agents/ antibiotics as diarrhea and the progression
indicated of this condition to
dehydration.
Name: Louisse Natasha Valeria Age: 4 years old Sex: Female

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Diarrhea related After 4 hours of Independent: After 4 hours of nursing

to the presence nursing interventions, the patient
-Observe and record stool -Helps differentiate
of toxins. interventions, the was able to report reduction
frequency, characteristics, individual disease and
“Madalas po siyang patient will report in frequency of stools.
amount and precipitating assesses severity of episode.
dumumi ngayon kaysa reduction in factors.
kahapon” as verbalized by frequency of stools.
the father.
-Promote bed rest. -Rest decreases intestinal
Objective: motility and reduces
metabolic rate.

 Increased
peristalsis -Urge to defecate may occur
-Provide bedside commode. without warning and
 Frequent watery
uncontrollable, increasing
stools.
risk of incontinence or falls if
 Abdominal pain.
facilities are not close at
 Vital signs taken
hand.
as follows:
BP= 110/90mmHg
PR= 80bpm -Identify foods and fluids -Avoiding intestinal irritants
RR= 18cpm that precipitate the diarrhea promotes intestinal rest.
Temperature= 36.6⁰ of the patient.
-Restart oral fluid intake -Provides colon rest by
gradually. Offer clear liquids omitting or decreasing
hourly, and avoid cold fluids. stimulus of foods or fluids.
Gradual consumption of
liquids may prevent cramping
and recurrence of diarrhea.
Cold fluids can increase
intestinal motility.

-Encourage to eat foods like -Fruits that are stool former.

banana and apple.

-Avoid foods that are oily, -Foods that may precipitate

spicy and caffeine. gastric cramping.

Dependent:
- Administer anti-diarrheals -Decreases G.I motility or
as prescribed by the peristalsis and diminishes
physician. digestive secretions to relieve
cramping and diarrhea.
Name: Samantha Maureen Vera Age: 6 years old Sex: Female

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Risk for deficient After 8 hours of Independent: After 8 hours of nursing
fluid volume r/t nursing interventions, the patient
-Monitor intake and output, -Provides information about
excessive losses interventions, the was able to reduce the
character and the amount of overall fluid balance, renal
“Sumasakit po ang tiyan through frequent patient will reduce frequency of defecation
stools; estimate insensible function, and bowel disease
niya at anim na beses na diarrhea. the frequency of fluid losses. Measure urine control, as well as guidelines from 6 to 2 and maintain
po siyang dumudumi defecation and adequate fluid volume as
specific gravity and observe for fluid replacement.
ngayong araw” as maintain adequate evidenced by good skin
for oliguria.
verbalized by the sister of fluid volume as turgor and balance intake
the patient. evidenced by good and output..
skin turgor and -Assessing vital signs -Hypotension (including
balance intake and
Objective: postural), tachycardia, fever
output
can indicate response to or
effect of fluid loss.
 Restlessness
 Irritability. -Observe for excessively dry -Indicates excessive fluid loss
 Facial Grimace skin and mucous or resultant of dehydration
 Dry Skin membranes, decreased skin caused by diarrhea.
 Vital signs taken turgor, slowed capillary
as follows: refill.
BP= 110/70 mmHg
PR= 79 bpm
RR= 19 cpm
Temperature= 37.4⁰ -Indicator of overall fluid and
-Weigh daily
nutritional status.
-Observe for overt bleeding -Inadequate diet and
and test stool daily for occult decreased absorption may
blood. lead to vitamin K deficiency
and defects in coagulation,
potentiating risk for
hemorrhage.

Dependent:
-Maintenance of bowel rest
-Administer parenteral
requires alternative fluid
fluids as indicated.
replacement to correct
losses.

-Administer medications as -To reduces fluid losses in the

indicated: Anti-diarrheal intestine and to prevent
and antibiotics. further spread of the
bacteria.
DEHYDRATION
Name: Ashianna Kim Fernandez Age: 6 years old Sex: Female

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Fluid Volume At the end of 16hrs Independent: After 16hours of nurse-
deficit related to nurse-client client intervention, the
1. Assess vital signs; note -To evaluate degree of fluid
loose watery intervention, the client was able to:
strength of peripheral deficit.
“Namumutla po siya tapos stool (Diarrhea). client will be able to:
pulses. 1. Maintain the fluid
yung labi niya po dry na
volume at its
dry n” as verbalized by the
functional level.
mother of the patient. 1. Maintain fluid 2. Keep fluids within clients -to correct/ replace losses to
2. Verbalize
volume at a reach and encourage reverse pathophysiologic understanding of
functional level as frequent intake as mechanisms.
Objective: causative factors
evidenced by appropriate.
and purpose of
individually
individual
adequate urinary
 Decreased urine therapeutic
output with 3. Control humidity and -To reduce high fever and
output interventions and
normal specific ambient air temperature as elevated metabolic rate.
 Poor skin turgor medications.
gravity, stable appropriate. Reduce
 Vital signs taken vital signs, moist beddings/clothes, provide
as follows: mucous tepid sponge bath.
BP= 100/80 mmHg membranes,
PR= 84 bpm good skin turgor
RR= 21 cpm and prompt 4. Change position -To promote comfort and
Temperature= 37.7⁰ capillary refill. frequently. safety.
2. Verbalize
understanding of
causative factors
and purpose of 5. Provide safety measures -To promote safety.
individual when client is confused.
therapeutic
interventions and Dependent:
medications.
1. Administer medications -To limit gastric/intestinal
as indicated.(antidiarrheals) losses.

2. Establish 24-hour fluid -To prevent peaks/valleys in

replacement needs and fluid level.
routes to be used.

3. Administer IV fluids as -To replace losses to reverse

indicated. pathophysiologic
mechanisms.
Name: Avianna Rye Diaz Age: 4 years old Sex: Female

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Fluid Volume After 8 hours of Independent: After 8 hours of nurse-client

Deficit related to nursing intervention, intervention, the client was
a. Assess vital signs -Provides baseline for
active fluid the client will be able able to maintain fluid
assessing and evaluating
“Nagsusuka siya tapos volume loss (e.g to maintain fluid volume at a functional level.
interventions.
maputla. Minsan sinasabi diarrhea) volume at a functional
niya na masakit ang level.
kanyang tiyan.” As b. Note physical signs of -Predictors of fluid balance
verbalized by the patient’s dehydration that should be in client’s
grandmother. usual range in a healthy state.

Objective: c. Encouraged fluid intake -To detect early signs of

and monitoring of daily fluid dehydration
intake and output
 Palor
 Appeared weak
 Vital signs taken d. Offer the client ice chips -Fluid electrolyte
as follows: followed by clear liquids replacement provides oral
BP= 110/60 mmHg replacement therapy
PR= 75 bpm
RR= 18 cpm
Temperature= 36.7⁰
Dependent:
- To limit gastric/intestinal
1. Administer medications
losses; to treat bacteria
(antiemetics or
antidiarrheals or antibiotics)
as indicated.
Name: Clyden Jaile Ramirez Age: 8 years old Sex: Male

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Deficient Fluid Short Term: Independent: Short Term Goal:

Volume r/t
After 2hrs of • Established rapport -To gain trust and confidence
Profuse Bowel
continuous nursing to the client and significant
“Madalas kasi ang Movement for 3- GOAL SUCCESSFULLY MET
care and proper others
pagtatae ng baby ko kaya 5 times a day
health teachings the After 2hrs of continuous
para siyang nauubusan ng secondary to • Monitored and -To obtain baseline data
patient will manifest: nursing care and proper
tubig” As stated by the Inflammation of recorded v/s
health teachings the patient
mother the stomach and •Decrease risk for • Provide proper -To avoid other fluid loses manifested:
intestine complications of Fluid ventilation and cool through excessive sweating.
Objective:
volume deficit •Decreased risk for
environment
complications of Fluid
•Significant others
volume deficit
 Dry mucous will have the proper
membrane knowledge regarding Health Teachings done to • Significant others acquired
 Slightly sunken the disease. the S.O.: proper knowledge regarding
fontanels the disease.
•Significant others • Instructed to Inc. -To maintain hydration
 With fair skin
will know the proper Oral Fluid intake of the client status, thus, avoiding •Significant others
turgor dehydration. understand the intervention
intervention of the
 Vaguely weak in problem. of the problem.
appearance • Advised proper -To avoid reoccurrence of the
 Defecated 3x to a hygiene of the client disease
yellowish watery Long Term: Long Term:
stool at
approximately 1- After 2 days of • Adequate rest and -To avoid exhausting the Still on further Evaluation.
3tsp. continuous nursing sleep should be provided patient, this may lead more
 On Breastfeeding care and proper on fluid loss.
with good sucking health teachings the
ability client will maintain
 Weight -8kgs. fluid volume at Dependent:
(upon admission) functional level as
-6kgs. (upon evidenced by: •IVF administered as -To deliver fluids accurately
assessment) ordered. Maintained at at desired rates.
•Normalized Bowel proper regulation
 Vital signs taken Movement
as follows:
BP= 110/60 mmHg •Moist mucous
membrane and good •Medications given as -An antibiotic kills/diminishes
PR= 85 bpm
skin turgor. prescribed: the microorganisms causing
RR= 23 cpm
the disease, thus, preventing
Temperature= 37.3⁰ -Pen G 400,000 TIV every 6
manifestation to occur.
hrs
Name: Kalix Jace Martinez Age: 8 years old Sex: Male

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Fluid Volume Within 8 hours, Independent: Goal met.

Deficit related to patient will maintain
 Monitored vital signs; -> Increased HR along with Patient maintained
excessive adequate fluid
noted changes in decreased BP and elevated adequate fluid volume as
“Sobrang nauuhaw po urination volume as evidenced
body temperature. temperature, is present in evidenced by N vital signs,
ako,” as verbalized by the secondary to by:
conditions with fluid volume adequate urinary output
patient. diabetes
> vital signs within deficit. Increased body with normal specific gravity,
insipidus
normal range for age temperature also increases moist mucous membranes,
Objective: fluid loss by increasing good skin turgor, and
> urine output of 50-
metabolism. patient’s verbalization that
80ml/hr
thirst is not excessive.
 excessive thirst > urine specific gravity
between 1.004 and  -> Patients with may
 dry oral mucous Observed for
1.030 postural BP changes; experience varying degrees
membranes
encouraged gradual of postural hypotension
 severe polyuria > moist mucous
position changes. depending on degree of fluid
(>7L/day) membranes
Palpated peripheral volume deficit.
 urine specific > good skin turgor
gravity= 1.001 pulses, assessed
 decreased skin > patient verbalizing capillary refill,
turgor that thirst is no longer mucous membranes,
excessive and skin turgor;
 Weakness
observed for changes
 irritability
in mental status.
 Vital signs taken
as follows:
BP= 80/57 mmHg
 Monitored I/O qh; -> Excessive fluid loss through
PR= 92 bpm
obtained daily regulatory mechanisms
RR= 25 cpm
weights and failure may result in severe
Temperature= 38⁰
 compared with 24 hr dehydration, circulatory
I/O. collapse and shock.
Decreased cerebral perfusion
may result in changes in
mentation.

 Encouraged increase -> Fluid replacement needs

in fluid intake and are based on correction of
consumption of current deficits and ongoing
foods high in fluid losses. Decreased urinary
content. output may require
aggressive fluid replacement.

 Monitored IV flow -> Patients on IV fluid therapy

rates regularly; may be at risk for
observed for marked cardiopulmonary
elevations in BP, compromise.
restlessness, moist
cough, dyspnea,
basilar crackles, and
frothy sputum.

 Provided health
teachings on the -> Lifelong fluid replacement
need for lifelong to control polyuria and
hormonal polydipsia is necessary for
replacement. patients with Diabetes
Insipidus.

Dependent:
 Administered IV -> Aggressive fluid
fluids as ordered. replacement may be required
to correct fluid volume
deficit.

 Administered -> Desmopressin is the drug

desmopressin of choice for Diabetes
(DDAVP) intanasally Insipidus.
as ordered.

Collaborative:
 Monitored -> Other imbalances that
laboratory studies require correction may be
such as urine specific present with fluid volume
gravity, electrolytes, deficit
and blood
coagulation studies
GLOMERULO NEPRHITIS
Name: Amora Elyse Ledezma Age: 3 years old Sex: Female

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Excess Fluid Short term: Independent: Goal met

volume related
 After 1 hour of 1. Assess fluid status - Assessment provides
to failure of
nursing baseline and ongoing
“Nagmamanas ang mukha regulatory a. Daily weight >The patient demonstrated
intervention the database for monitoring
ng anak ako” as vervalized mechanism compliance with dietary and
patient will b. Monitor I & O changes and evaluating
by the patient’s mother. (inflammation of fluid restrictions, blood
glomerular
demonstrate c. Skin turgor and presence interventions pressure is within the
compliance with of edema normal limit (110/80mmHg)
membrane
Objective: dietary and fluid
inhibiting d. BP, PR,RR
restrictions
filtration)
 After an hour of >Fluid volume is stabilized as
evidenced by
 Facial Edema weight gain,
nursing
2. Limit fluid intake to -Fluid restriction will be manifested by free from
 Vital signs taken edema, intervention the
and prescribe volume and determined on basis of signs of edema and vital
as follows: patent’s blood
blood pressure explain to patient and family weight, urine output and signs are in normal limits
BP= 110/60 mmHg pressure will be
changes the rationale. response to therapy.
PR= 85 bpm within normal
limits(systolic of Understanding promotes
RR= 23 cpm
105 +/- 13) patient and family
Temperature= 37.3⁰
cooperation with fluid
restriction.
Long term:
 After 1 week of
3. Assist patient to cope with - Increasing patient comfort
nursing care and
the discomforts resulting promotes compliance with
management dietary restrictions.
from fluid restriction.
fluid volume of
the patient must
stabilize, free
from signs of
edema and vital 4. Teach the mother to -These are indications of
signs within report signs of fluid inadequate control of
normal limits. overload, vision changes, hypertension and the need to
headaches, edema, or alter therapy.
seizures.

Dependent:
1. Monitor and record blood - Provides objective data for
pressure as indicated. monitoring. Elevated levels
may indicate non-adherence
to the treatment regimen.

2. Administer hypertensive -Antihypertensive

medications as prescribed. medication play a key role in
treatment of hypertension
associated with AGN.
Name: Larkin Olivier Sanchez Age: 5 years old Sex: Male

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Excess Fluid Short term: Independent:

volume related
 Client will have an 1. Obtain complete physical - To have baseline data on the Client had a total urine
to failure of
increased urine assessment. progress of fluid elimination output of 72 ml 4 hours after
“I felt mutated with this regulatory
output of 70-80 through physical appearance. the implementation of the
enlarged arms and feet mechanism.
ml for the next 6 nursing interventions.
since if suffered from this - To have a measurable
hours. 2. Monitor daily weight.
illness,” as verbalized by account on the fluid
the patient. Long term: elimination.
Client had edema of (+) 1 the
Objective:  Client will have a 3. Monitor fluid intake and - To know progressing second day of nursing
sustained output every 4 hours. condition via glumerular intervention. Patient also
minimum urine filtration. had an average of 24 ml of
 +3 edema on both output of 20 ml urine output for the last 10
4. Monitor BP and PR every - To know progression of
foot hours.
per hour and hypertension and basis for
 +2 edema on both hour.
manifest lesser further nursing intervention
hands
edema (+) 1. or referral.
 (+) periorbital
edema
 (+) proteinuria 5. Assess for adventitious - To know for possible
 30 ml urine breath sounds. progression in the lungs.
output for the last - To know the extent of
6. Monitor laboratory values
8 hours protein loss which led to
especially for the protein
 Vital signs taken edema.
level in the urine.
as follows:
BP= 140/90 mmHg
PR= 120 bpm 6. Maintain dietary 6.
RR= 29 cpm restrictions during acute
Temperature= 38⁰ phase.
a. sodium a. to help prevent fluid
retention via absorption.

b. protein b. it helps prevent fast

elevation of BUN level.

7. Maintain fluid restriction 7. Helps prevent further fluid

accumulation while there is
decreased glumerular
filtration.
8. Elevate extremities with 8. Helps fluid excretion via
pillows when at rest or at gravity.
lying position.
Educative:
1. Encourage ambulation 1. Helps increase blood and
and non strenuous fluid circulation.
exercises.
2. Reinforces awareness on
2. Teach on the importance its effect on fluid excretion.
of elevating extremities
when at rest.
3. Encouraged to maintain 3. Helps prevent skin
clean and moist skin. breakdown and further
infection arising from the
skin.

4. Encouraged to stick on 4. For client cooperation even

dietary and fluid in the absence of any
restrictions. medical practitioner.
Dependent:
1. Administer antibiotics as -Fights infection and
ordered. progression of scarring.

2. Administer anti -Controls hypertension as

hypertensive drugs as caused by excessive fluid.
ordered.
Name: Kierra Valeria Ynare Age: 4 years old Sex: Female

Assessment Nursing Diagnosis Goal Intervention Rationale Evaluation

Objective: Excess fluid Short-term Goals: Independent: Short-term Goals:

volume related to
 After 3 hours of 1. Elevate edematous - To reduce tissue pressure Goals met. After 3 hours of
accumulation of
thorough nursing extremities, change and risk of skin breakdown. thorough nursing
 Edema fluids in the body
intervention, the position frequently. intervention, the patient
 Decreased Hb secondary to acute
patient will be was be able to gradually
(8.4) /Hct (26.2) glomerulonephritis
able to: excrete excessive fluid
 Change in mental  Gradually 2. Assist and/or encourage - It aids in the mobilization of through urination and
status: restless excrete excessive client to turn to sides every fluids to easily excrete demonstrated behaviors
 Abnormal fluid through 2 hours. through urination. that would help in excreting
increase of urination. excessive fluids in the body.
abdominal girth  Demonstrate
(77cm) 3. Allow client to hear - To promote diuresis Long- term Goals:
behaviors that
 Vital signs taken would help in running water. Goals met. After 2 days of
as follows: excreting thorough nursing
BP= 140/90 mmHg excessive fluids intervention, the client was
PR= 120 bpm 4. Apply hot and cold - To stimulate urination. be able to excrete
in the body.
RR= 29 cpm compress on the client’s completely excessive fluids
Temperature= 38⁰ bladder (just above as manifested by the
Long- term Goals: symphisis pubis). absence of edema and
improved the distended
 After 2 days of abdominal girth from 77cm
thorough nursing 5. Encourage bed rest - May promote recumbency-
to 67cms.
intervention, the if ascites is present. induced diuresis.
client will be able
to:
 Excrete
completely
excessive fluids
 as manifested by Dependent:
the absence of
edema. 1. Administer diuretic - To increase water
 Improve the (furosemide 20 mg IVTT excretion.
distended every 8 hours;
abdominal girth spironolactone 25 mg 1 tab
from 77cm to BID), as ordered
67cms.
2. Administer albumin - Because it helps in the
20% IVTT for 30 minutes shifting of fluids from ISC to
every 12hours IVC.
Name: Shan Lopez Age: 7 years old Sex: Male

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Skin Integrity due After 8hours of Independent: On the second day of duty,
to limited fluid nursing the patient has improved
• Monitor vital signs > Knowledge of vital signs
intake as interventions, the hydration manifested by
allows physicians to
“Nauuuhaw pa po ako” as resolution to patient’s discomfort lesser chapping of lips and
understand patient’s
verbalized by the patient. edema in will be decreased and lesser drying of the mouth.
physiologic status and is
Objective: treatment of will demonstrate use
helpful in determining The patient can cope with
Acute of relaxation skills
appropriate goals. the limited of fluid intake by
Glumerular and other methods
lessening activities which
 Dry and chapped Nephritis. to promote comfort. • Monitor weight gain and >This could give further
could make her thirsty and
lips loss. information on the patient’s
sweat.
water retention problem
 Dry mucous
The patient is doing
membrane • Advise patient to wear >To promote comfort to
The patient to diversional activities to
(mouth), Fluid volume patient on a humid and hot
maintain fluid light clothing. redirect her attention from
 Complaints of deficit related to day, to lessen sweating
volume at a being thirsty.
thirst inadequate
functional level as • Suggest sleep or do light > These are diversional
 Decreased skin intake of fluids.
turgor
indicated by moist reading as diversional activities to redirect
mucous membranes, activity. attention from being thirsty
 Slight irritability
good skin turgor,
due to thirst
adequate urinary • Bathing every other day, >To promote hygiene and
 Increase BP output and no sponge bath only on prevents drying of skin
110/80 discomfort in intervals
 Vital signs taken defecation and
as follows: regular bowel
BP= 110/80 mmHg movement. • Apply wet cotton balls on >To prevent further dryness
PR= 119 bpm dry and chapped lips and skin breakdown
RR= 24 cpm
Temperature= 37.3⁰
• Straighten wrinkled linens > To lessen friction on dry
to lessen friction on dry skin skin , to prevent skin
breakdown

Dependent:
 Administer diuretics > This is resolution for the
and antibiotics as complications of edema
ordered by Physician.
NEPHROTIC SYNDROME
Name: Avrielle Haven Juarez Age: 4 years old Sex: Female

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Excess fluid  After 8 hours of Independent: After 8 hours of nursing

volume related nursing interventions, the patient
•Record accurate intake and •Accurate Intake and output
to compromised interventions, was able to display stable
output of the patient. is necessary for determining
“Namamanas ang kanang regulatory the patient will weight, vital signs within
renal function and fluid
binti ng anak ko” (My son mechanism with display stable patient’s normal range, and
replacement needs and
has a massive edema on changes in weight, vital nearly absence of edema.
reducing risk of fluid
his lower right leg) as hydrostatic or signs within overload.
verbalized by the mother. oncotic vascular patient’s normal
Objective: pressure and range, and
increased nearly absence
activation of the •Monitor urine specific • Measures the kidney’s
of edema. ability to concentrate urine.
rennin- gravity.
 Edema
 Weight gain angiotensin-
 Changes in vital aldosterone • Daily body weight is the
•Weigh daily at same time
signs system. best monitor of fluid status. A
of the day, on same scale,
 Vital signs taken with same equipment and weight gain of more than 0.5
as follows: clothing. kg/day suggest fluid
BP= 110/60 mmHg retention.
PR= 85 bpm
RR= 21 cpm
Temperature= 37.3⁰ • Assess skin, face, • Edema occurs primarily in
dependent areas of edema. dependent tissues of the
body. It will serve as
parameter the severity of
fluid excess.
• Monitor heart rate and • Tachycardia and
blood pressure. hypertension can occur
because of failure of the
kidneys to excrete urine.

• Assess level of • May reflect fluid shifts and

consciousness; investigate electrolyte imbalances.
changes in mentation,
presence of restlessness.
Collaborative
• Monitor laboratory and • Monitor laboratory and
diagnostic studies. diagnostic studies.

• Administer diuretics as • Administer diuretics as

prescribed. prescribed.
Name: Estella Valeria Martinez Age: 3 years old Sex: Female

Assessment Nursing Diagnosis Goal Intervention Rationale Evaluation

Subjective: Excess fluid volume After 8 hours of Independent: After 8 hours of nursing
related to nursing interventions, the patient
“Namamaga ang mukha • Monitor vital Signs • For base line data
compromised interventions, the was able to display a stable
niya” as verbalized by
regulatory patient will display a • Record accurate intake • Accurate Intake and output condition, vital signs within
the father of the patient. mechanism with stable condition, and output of the patient. is necessary for determining patient’s normal range, and
changes in vital signs within renal function and fluid nearly absence of edema.
Objective:
hydrostatic or patient’s normal replacement needs and
oncotic vascular range, and nearly reducing risk of fluid
 Facial puffiness pressure and absence of edema. overload.
 Bipedal edema increased
activation of the • Monitor urine specific • Measures the kidney’s
 Vital signs taken gravity. ability to concentrate urine.
as follows: renninangiotensin–
BP= 160/70 mmHg aldosterone
PR= 57 bpm system.
• Weigh daily at same time • Daily body weight is the
RR= 12 cpm of the day, on same scale, best monitor of fluid status.
Temperature= 36.1⁰ with same equipment and A weight gain of more than
clothing. 0.5 kg/day suggest fluid
retention.
• Edema occurs primarily in
• Assess skin, face,
dependent tissues of the
dependent areas of edema.
body. It will serve as
parameter the severity of
fluid excess.

• Monitor heart rate and • Tachycardia and

blood pressure. hypertension can occur
 because of failure of the
kidneys to excrete urine.

• Assess level of • May reflect fluid shifts and

consciousness; investigate electrolyte imbalances.
changes in mentation,
presence of restlessness.

Collaborative
• Provide assessment of the
• Monitor laboratory and
progression and
diagnostic studies.
management of the
dysfunction.
• Administer diuretics as • To promote adequate
prescribed urine volume that aids in
prevention of further
edema.
Name: Haze Limuel Juarez Age: 9 years old Sex: Male

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Excess fluid After 8 hours of Independent: After 8 hours of nursing

volume related nursing interventions, the patient
"Marami siyang iniinom na 1.Assess and monitor - Identifies nutritional
to compromised interventions, the was able to display a stable
gatas nakakapitong bote food/fluid ingested deficits/ therapy needs
regulatory patient will display condition, vital signs within
siya ng gatas pero konti
mechanism with stable weight, vital 2. Monitor weight daily at - To assess the health status patient’s normal range, and
lang iniihi niya" as
changes in signs within patient's same time, same clothing of patient. Same clothing, nearly absence of edema.
verbalized by the mother.
hydrostatic or normal range, and and same scale. same time and same scale
oncotic vascular nearly absence of makes the weight equal/fair
pressure and edema. than yesterday.
Objective:
increased
activation of the 3. Recommend small, - Smaller portions may
 Edema renin- frequent meals. enhance intake
 Weight gain over angiotensin-
short period of aldosterone
time system as Dependent:
 Vital signs taken evidence by
1. Restrict sodium as - This electrolyte can
as follows: edema.
indicated, and limit fluid quickaccumulate, causing
BP= 140/80 mmHg intake to 100ml fluid retention, and
PR= 68 bpm weakness.
RR= 15 cpm
Temperature= 37.1⁰ 2. Administer multivitamins, - Replaces vitamin/mineral
as indicated. deficits resulting from
malnutrition

3. Administer medications - Reduces stimulation of the

as appropriate. vomiting center
4. Administer diuretic ass - To promote adequate urine
prescribed volume

Collaborative

1. Monitor laboratory - To assess development and

studies status.

2. Monitor laboratory and - Provide assessment of the

diagnostic study progression and
management of dysfunction.
Name: Acel Chelvea Peña Age: 8 years old Sex: Male

Assessment Nursing Goal Intervention Rationale Evaluation

Diagnosis

Subjective: Excess fluid Short term: Independent:  Display appropriate

volume related urinary output with
"Namamanas po ang binti  Increased 1.Record accurate intake - Low output (less than
to compromised normal specific
niya" as verbalized by the urinary and output (I&O). 400ml/24hr) is the first
regulatory gravity and
mother. output. indicator of acute renal
mechanism with laboratory status
 Minimize failure.
changes in within normal
presence of
Objective: hydrostatic or range.
edema. 2. Monitor urine specific - To measure the kidney’s
oncotic vascular  Absence of edema
 Achieve gravity. ability to concentrate urine.
pressure and and body weight
stable weight
 Oliguria increased returns to normal.
and stable
 Weight gain activation of the  Vital signs with
vital sign.
 Vital signs taken renin- normal range.
angiotensin- 3. Weigh daily at the same - Daily body weight is best
as follows:
aldosterone time of the day. monitor of fluid status. A
BP= 130/80 mmHg Long Term:
system as weight gain of more than
PR= 98 bpm
RR= 18 cpm evidence by  Prevents 0.5kg/day suggest fluid
edema. complication retention.
Temperature= 36.4⁰
of the
disease.
4. Monitor heart rate and - Tachycardia and
bp. hypertension can occur
because of failure of the
kidney to execrate urine.

5. Elevate edematous body - To promote venous return.

part.
Collaborative

1. Monitor serum sodium. - Hyponatremia may result

from fluid overload or
kidney’s inability to conserve
sodium. Hypernatremia
indicates total body water.
NUTRITION
 Assessment Nursing Goal Implementation Rationale Evaluation
Diagnosis
 Prepare Low Fiber  After 2 days of
Objective: Acute  After 1-3 - The fiber in food
Malnutrition and Diet. Low fiber diet provides the nursing
days of
nutrient can include the roughage of bulk that intervention, the
nursing
 Weight Loss deficiency following: stimulates the bowel. patient was able to
intervention,
 Restlessness -Banana, cooked regain weight and
related to the patient A low fiber diet is
fruits without skin nutrition that were
 Palor diarrhea. will regain better tolerated with
or seeds, fruit juices lost due to diarrhea,
 Nutrition weight and diarrhea because it
without pulp, apple will not stimulate and the patient also
Deficiency nutrient loss,
sauce. re-established and
 Nausea and and re- bowel as much and it
-Green vegetables will be easier to maintain normal
Vomiting establish and
-White rice, bread digest. skin color and
maintain
products made with pattern of bowel
normal skin
refined white flour, functioning.
color and
graham crackers.
pattern of
-Oatmeal and cold
bowel
cereals
functioning.
-Meat, poultry, fish,
eggs and milk.

 Can also give BRAT

- Helps to find the
Diet. BRAT stands
right amount of fiber
for Banana, Rice,
Applesauce and for optimum health
Toast Diet. without making
symptoms worse.

:
 Assessment Nursing Goal Implementation Rationale Evaluation
Diagnosis
 Prepare Bananas,  After 3 days of
Objective: Severe Acute  After 1-3 - Bananas are
Malnutrition coconut water, excellent source of nursing
days of
caused by cucumber, potassium, since intervention, the
nursing
 Dry Skin dehydration. watermelon and dehydration come patient was able to
intervention,
 Poor Skin Turgor celery for retain fluid and
the patient with the loss of
dehydration electrolyte balance,
 Palor will be able potassium, bananas
management and regain weight by
 Weak in to retain the can retain those lost
retention of potassium. giving adequate
appearance fluid and
nutrients. food and meal plan,
 Weight Loss electrolyte - A glass of coconut
and maintain
 Dizziness imbalances, water is abundantly
normal nutritional
 Fainting regain the rich in sodium and
status.
 Decreased muscle weight potassium that can
mass supported by bring back the loss
giving nutrients
adequate considerably.
food and - Cucumber is one the
meal, and best hydrating foods.
maintain It is a good source of
normal fiber and rich in
nutritional Vitamin C.
status. - Watermelon is a
wonder fruit that
contains 95 % of
water. It is also rich in
lycopene, an
antioxidant, essential
for the regulation of
 water balance in the
body.
- Celery is rich in iron,
sodium, potassium
and zinc. It contains
the highest level of
water content
compared to other
vegetables. It is also a
good source of folate
and B-vitamins.
 Assessment Nursing Diagnosis Goal Implementation Rationale Evaluation

 Prepare low - Renal Vascular  After 3 days of

Objective: Nutritional  After 1-3 days
protein diet. Loss resistance fell nursing
deficiency related of nursing
protein foods, during a high intervention, the
to acute intervention,
 Fatigue potassium, protein diet and patient was able to
glomerulonephritis. the patient
phosphorus and increased when re-establish and
 Anemia will be able to
salt. dietary protein is maintain good
 High blood show signs of
restricted. Low nutritional status as
pressure maintaining
protein diet helps to evidence by
 Proteinuria and re-
benefit in glomeral adequate meal
 Lethagy establishment
disorders. intake for the 2
 Decreased in of good
whole days.
Nutritional status nutritional
- too much fluid in
 Lack of appetite status as  Drink less fluids. the body, which can
 Weight Loss evidenced by
cause swelling in
adequate
places like the face,
meal plan.
feet, ankles, or legs.

 Low sodium (salt) - helps with swelling

in the hands and
legs

 Give Calcium
supplements
 Give medicines to
lower the blood
pressure level
 Assessment Nursing Goal Implementation Rationale Evaluation
Diagnosis
 Prepare low protein - Since too much  After 4 days of
Objective: Risk for  After 1-4
and sodium diet. It protein is dangerous nursing
malnutrition days of
can include the because it can intervention, the
related to nursing
 Fatigue following: damage nephrons or patient was able to
nephrotic intervention,
-Lean meats the functioning units retain nutrients
 Loss of appetite syndrome. the patient
(Poultry, fish, of kidneys and can needed and re-
 Weight gain due will be able
shellfish) cause renal established normal
to edema to retain
-Dried beans insufficiency, low- nutritional status.
 Protein loss nutrients
-Fresh or frozen protein diet is
 Hematuria needed and
fruits recommended.
 Proteinuria re-establish
-Low-sodium - A low sodium diet
normal
canned vegetables too is recommended
nutritional
-Whole grains because too much
status.
-Potatoes sodium can cause
-Milk further fluid
-Rice retention and salt
-Whole grains retention.