Name: Merla Amigo Ward: DMC-Medical Ward

Age: 45 years old

Medical Diagnosis/Impression: Chronic Renal failure secondary to Hydronephrosis

Date Cues Nursing Diagnosis Needs Planning Implementation/Intervention Evaluation

& Goals/Objective
Time
SUBJECTIVE:“ Fluid Volume N After 8 hours 1. Established rapport. After 8 hours span of
S Maglisod ko ug excess r/t U of span of ® To gain trust & cooperation of patient. care, the patient had:
E ginhawa” as Compromised T care, the 2. Monitored vital signs.
R
P verbalized by regulatory patient will: ® To monitor patient’s over-all status. • No urinary output
I
T the patient. mechanism 3. Record accurate intake and output because she has
T
E I • display (I&O). limited her oral fluid
M OBJECTIVE: O appropriat ® Accurate I&O is necessary for intake to almost not
B ® When patient has N e urinary determining renal function and fluid drinking unless thirsty
E • Venous renal failure, there is A output replacement needs and reducing risk of and she also has no
R distension decreased blood flow L • vital signs fluid overload. IVF.
• anasarca in the kidneys which - within 4. Weigh daily at same time of day, on • Vital signs are within
• orthopnea will decrease kidney M same scale, with same equipment and normal ranges.
patient’s
3, tissue perfusion that E clothing. • Edema still present.
• oliguria T
normal
• V/S taken causes decreased range; ® Daily body weight is best monitor of
urine output and water A
as follows B • absence of fluid status.
2 will retain in the body. 5. Assess skin, face, and dependent areas Goal Partially Met.
O edema.
-T: 36.0˚C L for edema.
0 Bibliography: I ® Edema occurs primarily in dependent
-P: 65
Doenges, Marilyn et. C tissues of the body, e.g., hands, feet,
-R: 18
1 Al.2008. Nurse’s lumbosacral area.
-BP: 120/80
Pocket Guide.F.A. P 6. Limit fluids as indicated.
0 Davis Company A ® Fluid management is usually calculated
T to replace output from all sources plus
@ T
estimated insensible losses
E
R 7. Administer medications as indicated.
11pm ®Given early in oliguric phase of Renal
N
Failure in effort to convert nonoliguric
phase, flush the tubular lumen of debris,
 reduce hyperkalemia, and promote
adequate urine volume.

DAVAO MEDICAL SCHOOL FOUNDATION

Medical School Drive, Bajada, Davao City

In Partial Fulfillment of the Requirements in NCM 104-RLE DMC-MEDICAL Ward Expoxure

A Nursing Care Plan

Submitted to:

Ms. Arlyn Almoite, RN

Clinical Instructor

Submitted by:

Regine Delfinado

BSN 4A
September 4, 2010