Medical Diagnosis: Chronic Kidney Disease Stage 5

Patients name: Patient J.P.

Assessment Diagnosis Inference Planning Intervention Rationale Evaluation
Subjective:
Nandito ako kasi
nahihirapan akong
huinga! "a"o na pag
nagsasa"ita# as
verba"i$ed by the
patient
%bjectives:
&S taken as
'o""o(s:
Temp: )*.+
RR: ,5cp
PR: -)bp
BP: .*/0../
Patient 1ani'ested:
2dea 3,
4ypertension
Pu"onary
Congestion
5S%6! D%67
%"iguria as
evidence by .5/
" per +hours
8"uid
&o"ue
29cess r0t
sodiu
retention
:pairs
g"oeru"ar
'i"tration
increase
hydrostatic
pressure
Pushing
e9cess
'"uids into
the
interstitia"
spaces
8"uid
vo"ue
over"oads
the "yph
syste
2dea!
pu"onary
congestion
and 4PN
;'ter <=+
hours o'
nursing
interventions
patient (i""
deonstrate
behaviours
to onitor
'"uid status
and reduce
recurrence o'
'"uid e9cess
.. 2stab"ish
rapport
,. 1onitor and
record vita"
signs
). ;ssess
patient>s
appetite
<. Note
aount0rate
o' '"uid
intake 'ro
a""
resources
5. ?ecord
occurrence
o' dyspnea
*. Note
presence o'
edea
@. ?estrict
sodiu and
'"uid intake i'
indicated
+. ?ecord : A%
accurate"y
and
ca"cu"ate
'"uid vo"ue
ba"ance
-. Proote
.. Bo assess
precipitating
and causative
'actors
,. Bo obtain
base"ine data
). Bo prevent '"uid
over"oad and
onitor intake
and output
<. Bo onitor '"uid
retention and
eva"uate
degree o'
e9cess
5. Bo deterine
'"uid retention
*. 1ay indicate
increase in
'"uid retention
@. Bo onitor
kidney 'unction
and '"uid
retention
+. :ndicated '"uid
retention and
edea
Bhe patient
sha"" have
deons=
trated
behaviours
to onitor
'"uid status
and reduce
recurrence
o' '"uid
e9cess
overa""
hea"th
easure
-. Bo proote
(e""ness
Assessment Diagnosis Inference Planning Intervention Rationale Evaluation
Subjective:
Buataas ng
tuataas yong 6CN
at Creatinine ko!
kaya ibes na
da"a(ang beses
"ang ako
agdidia"ysis! sabi
ng dokotor agiging
)=< na# as
verba"i$ed by the
patient
%bjectives:
&S taken as
'o""o(s:
Temp: )*.+
RR: ,5cp
PR: -)bp
BP: .*/0../
:ncrease in
Dab resu"ts
56CN!
Creatinine!
uric ;cid
Deve"7 as
evidence by
Creatinine:
5,/Eo"0D
;"tered
?ena"
Per'usion
r0t :ncrease
in 6CN!
Creatinine
and Cric
;cid
%ptia" ce""
'unctioning!
the kidney
e9crete
potentia""y
har'u"
nitrogenous
product
Doss o'
kidney
e9cretory
'unctions
:paired
e9cretion o'
nitrogenous
(aste
:ncrease in
Daboratory
resu"t o'
6CN!
Creatinine!
Cric ;cid
Deve"
;'ter ,=)
hours o'
Nursing
:nterventions
the patient
(i""
deonstrate
participation
in her reco=
ended
treatent
progra
.. 2stab"ish
?apport
,. 1onitor and
?ecord &S
). ;ssess
patient>s
genera"
condition
<. ;scertain
usua" voiding
pattern
5. Note
presence!
"oca" intensity
duration o'
pain
*. 1onitor 6P!
ascertain
patient>s usua"
range
@. Provide diet
restriction as
indicated!
(hi"e
providing
adeFuate
ca"ories
+. 2ncourage
discussion o'
.. Bo get the
cooperation o'
the patient
,. Bo obtain
base"ine data
). Bo obtain
base"ine data
<. Bo copare
(ith current
situation
5. 1ay indicate
pain on a''ected
organ
*. G8? ay
increase rennin
and raise 6P
@. Ca"ories to
eet body>s
need (hi"e
restriction o'
protein he"ps
"iit 6CN
+. Bo decrease
an9iety about
condition and
correct his
(ring ideas
about condition
-. Bo proote
Bhe patient
sha"" have
deonstrated
participation in
her
recoended
treatent
progra
BU:
,+ g0d"
Uric acid:
<++ Eo"0D
Pu"onary
Congestion
4ypertension
%"iguria as
evidenced by
.5/" per +
hours
'ee"ings
regarding
prognosis or
"ong ter
e''ect o'
discussion
-. :denti'y
Necessary
changes in
"i'esty"e and
assist c"ient to
incorporate
disease
anageent
to ;DDs
./. ;ssess
patient
eotiona"0psy
cho"ogica"
'actors
a''ecting the
current
situation
... Proote
overa"" hea"th
easure
(e""ness and
'urther
progression o'
cop"ication
./. Stress or
depression ay
be increasing
the e''ect o' an
i""ness or
depression
ight be the
resu"t o' being
'orced into
inactivity
... Bo proote
(e""ness
Assessment Diagnosis Inference Planning Intervention Rationale Evaluation
Subjective:
Nahihirapan ako
sa pag ihi# as
verba"i$ed by the
patient
%bjective:
:ncrease in
"ab resu"ts
56CN!
Creatinine!
Cric ;cid
Deve"7 7 as
evidence by
Creatinine:
5,/Eo"0D
BU:
,+ g0d"
Uric acid:
<++ Eo"0D
G8?: .5
%"iguria as
evidenced
by .5/"
per + hours
Crinary
?etention
:paired
Crinary
2"iination r0t
g"oeru"ar
1a"'i"tration
"oss o' kidney
'unctions
Decrease
G8?
Cannot
e9crete
nitrogenous
product and
'"uid
:paired in
Crinary
e"iination
;'ter ,=)
hours o'
nursing
interventions!
the patient (i""
verba"i$e
understanding
o' condition
.. 2stab"ish
rapport
,. 1onitor and
record vita"
signs
). ;ssess pt>s
genera"
condition
<. Deterine
c"ients
pattern o'
e"iination
5. Pa"pate
b"adder
*. Deterine
c"ient>s usua"
dai"y '"uid
intake
@. 2ncourage to
verba"i$e
'ear0concerns
+. 2phasi$e
the need to
adhere (ith
prescribe diet
.. Bo get the
cooperation
o' the patient
,. Bo obtain
base"ine data
). Bo kno(
(hat
prob"e and
interventions
<. Bo assess
degree o'
inter'erence
5. Bo assess
retention
*. Bo he"p
deterine
"eve" o'
hydration
@. %pen
e9pression
a""o(s c"ient
to dea" (ith
'ee"ings and
begin
prob"e
so"ving.
+. Bo prevent
aggravation
o' disease
condition
Bhe patient
sha"" have
deonstrated
participation in
his0her
recoended
treatent
progra