Name: Sumague, Maria Francheska O.

Date: October 5, 2019

Year & Section: BSN 3 – NCA 2

ACTUAL NURSING CARE PLAN

ASSESSMENT EXPLANATION OF PLANNING IMPLEMENTATION RATIONALE EVALUATION

THE PROBLEM
Subjective: Renal failure STO:  Record  Accurate I&O is STO:
“Di sya masyadong After 8 hours of accurate intake necessary for Goal is partially met.
nakakaihi. Konti konti effective nursing and output determining Patient has displayed an
lang yung nailalabas Decreased blood interventions, the renal function increase in urine output
nya kahit napapainom flow to the kidneys patient will display and fluid but not enough for the
naman naming sya ng appropriate urinary replacement normal level. Generalized
tubig.” output with specific needs and edema is still present.
Decreased gravity/laboratory  Weigh daily at reducing risk of
Objective: perfusion in the studies near normal. the same time fluid overload. LTO:
 Generalized kidneys of the day  Daily body Goal is partially met.
weakness LTO: weight is the Increase in the urine
 Generalized After 3 days of best monitor of output level has been
Edema Decreased urinary effective nursing  Position tubing fluid status. observed. Vital Signs
 Poorly output interventions, the and drainage have been near normal
controlled patient will be able pouch so that it  Blocked but Generalized Edema is
hypertension to maintain the allows drainage allows still present.
 Low urine Water retention appropriate urinary unimpeded pressure to build
output (200 ml output, stable flow of urine. within urinary
for 8 hours) weight, vital signs tract, risking
V/S: Fluid Volume within patient’s anastomosis
 T: 36.7 Excess normal range and leakage and
 BP: 210/140 absence of edema. damage to renal
 PR: 97 parenchyma.
 SPO2: 97%
Nursing Diagnosis:  Monitory Vital  Indicators of
Fluid Volume Excess Signs fluid balance.
related to Reflects level of
compromised hydration and
regulatory effectiveness of
mechanism as fluid
evidenced by replacement
Generalized Edema. therapy.