Name of Student: Dullan,Garnado,Irisari Section: BSN 3F Name of Patient: D.

M Age: 75 Sex: M Date: 08-24-10 Status: Widow NURSING CARE PLAN Medical Diagnosis: CKD secondary to hypertensive nephrosclerosis

Assessment Actual Cues:

Nursing Diagnosis Imbalanced Nutrition: Less than Body Requirements related to loss of taste or smell and unpalpable diet as evidenced by sudden weight loss.

Rationale

Desired Outcome After 5 days of Nursing Intervention, the client will be able to: Demonstrate progressive weight gain toward goal. Verbalize understanding of causative factors when known and necessary interventions. Demonstrate behaviors, lifestyle changes to maintain or regain appropriate weight.

Nursing Intervention

Justification

Evaluation After 5days of nursing intervention the client was be able to:

Sudden weight loss Poor muscle tone Pale mucous membranes

Age

Discuss with the client possible causes of decreased appetite.

Risk

Strengths Strong belief in God Positive outlook in life Good emotional and family support

Definition: intake of nutrients insufficient to meet metabolic needs.

Factors such as pain,fatigue, analgesic use and immobility can contribute to anorexia. Identifying a possible cause enables interventions to eliminate or minimize it. Poor oral hygiene leads to bad odor and taste, which can diminish appetite.

Encourage and help the client to maintain good oral hygiene.

Assessment Actual Cues:

Nursing Diagnosis Imbalanced Nutrition: Less than Body Requirements related to loss of taste or smell and unpalpable diet as evidenced by sudden weight loss.

Rationale

Desired Outcome After 5 days of Nursing Intervention, the client will be able to: Demonstrate progressive weight gain toward goal. Verbalize understanding of causative factors when known and necessary interventions. Demonstrate behaviors, lifestyle changes to maintain or regain appropriate weight.

Nursing Intervention

Justification

Evaluation After 5days of nursing intervention the client was be able to:
Goal met. Client client was able to demonstrate progressive weight gain toward goal Goal met. Client was able to verbalize understanding of causative factors.
Goal met. Client was able to demonstrate behaviors to maintain appropriate weight.

Sudden weight loss Poor muscle tone Pale mucous membranes

Age

Risk

Strengths Strong belief in God Positive outlook in life Good emotional and family support

Definition: intake of nutrients insufficient to meet metabolic needs.

Renal tissue loses function Interferes with the kidneys ability to maintain fluid and electrolyte homeostasis Decline in ability to concentrate urine Decrease in ability to exude phosphate,acid & K Imbalanced Nutrition

Discuss with the client possible causes of decreased appetite.

Factors such as pain,fatigue, analgesic use and immobility can contribute to anorexia. Identifying a possible cause enables interventions to eliminate or minimize it. Poor oral hygiene leads to bad odor and taste, which can diminish appetite.

Encourage and help the client to maintain good oral hygiene.

. Determine psychologica l factors or perform psychologica l assessment as indicated. .. To assess body image and congruency with reality.

Name of Student: Dullan,Garnado,Irisari Section: BSN 3F Name of Patient: D.M Age: 75 Sex: M Date: 08-24-10 Status: Widow NURSING CARE PLAN Medical Diagnosis: CKD secondary to hypertensive nephrosclerosis

Assessment Actual Cues:

Nursing Diagnosis Risk for powerlessness related to feeling of loss of control and lifestyle restrictions as evidenced by decreased physical strength

Rationale Renal tissue loses function Interferes with the kidneys ability to maintain fluid and electrolyte homeostasis Decline in ability to concentrate urine Decrease in ability to exude phosphate,acid & K Decreased physical strength Risk for powerlessness

Desired Outcome After 5 days of Nursing Intervention, the client will be able to: Verbalize positive self-appraisal in current situation

Nursing Intervention

Justification

Evaluation After 5days of nursing intervention the client was be able to: Goal met. Client was able to verbalize positive selfappraisal in his current situation. Goal met. Client was able to be involved in care and make choices. Goal met. Client was able to acknowledge reality that some areas are beyond his control.

Decreased mobility Decreased physical strength Body weakness

Age

Determine clients usual response to problems.

Risk

Strengths Strong belief in God Positive outlook in life Good emotional and family support

Definition: At risk for perceived lack of control over a situation and/or ones ability to significantly affect an outcome

Make choices related to and be involved in care.

Acknowledge reality that some areas are beyond individuals control.

Help client to identify personal strengths and assets.

*Nursing Diagnoses and Collaborative Problems Edition 4

To plan effective interventions, nurse must determine if client usually seeks to change his own behaviors to control problems or if he expects other or external factors Clients with chronic illness needs assistance to not see themselves as helpless victims.