NURSING CARE PLAN

Date assessed: December 11, 2017

Nursing
CUES Nursing Objective Nursing Intervention Scientific Explanation Evaluation
Diagnosis
Independent:
1. Record and monitor I
Subjective: Excess fluid After 8 hours of and O accurately. - Acute I & O is necessary After 8 hours of
“Minamanas na naman volume related to nursing interventions, 2. Monitor urine specific
to determine renal nursing interventions,
ako,” as verbalized by compromised the patient will display function. the goal was partially
gravity - Measure’s kidneys ability
the patient. regulatory appropriate urinary 3. Weigh daily at the to concentrate urine. met as evidence by;
Objectives: mechanism output with laboratory same time with the - Daily body weight is best urinary output of 500
- Urine output (renal failure). studies near normal, same clothes. monitor of fluid status. ml/day, BP: 140/90,
400 ml/day stable weight, and 4. Auscultate lung and - Fluid overload may lead weight of 64.59 kg.
- BP: 160/100 vital signs within heart sounds. to pulmonary edema and
5. Monitor BUN, HF.
- Weight gain client’s normal range. - Assess progression of
(63.3-66.5 kg) creatinine, K, Na,
renal dysfunction.
Hgb, Hct.
- Altered
Dependent: - Management for water
electrolytes 1. Administer diuretic as
- Low hgb, hct retention.
prescribed.
2. Administer anti- - Management for elevated
hypertensives as blood pressure.
prescribed.
3. Administer - Causes selective dilation
vasodilators as of the renal vasculature.
prescribed.
4. Prepare the patient - Done to correct volume
overload and electrolyte
for dialysis.
and acid-base imbalances
to remove toxins.
Drug Analysis
Nursing
Generic & Brand Contraindications
Frequency & Route Classification Action / Uses Side Effects Consideration /
Name & Precautions
Patient Teaching
1. Monitor BP and
pulse before
Generic Name: and during
Action: Contraindications: CNS: seizures,
Epoetin 100 units/kg administration.
Anti-anemics Stimulates -hypersensitivity to headaches
3x weekly Notify physician
erythropoeis. albumin CV: CHF, MI, stroke
Brand Name: if elevated
(production of red -uncontrolled HPN.
Erythropoietin 2. Monitor for
blood cells) -patients receiving Derm: transient
symptoms of
chemotherapy agents rashes
anemia (pallor,
Indications: -neutropenia
fatigue,
Anemia associated
dyspnea)
with chronic kidney Precautions:
3. May cause
disease. -Hx of seizures
increase in
-CVD
WBC and
-pregnancy
platelet and
-Lactation
decrease
bleeding times.
4. Caution in
pricking skin,
may cause
severe
bleeding.
5. Institute seizure
precautions.