Nursing care plan

Name: Garcia, Clarence Age: 2 years Old / Male Diagnosis: Acute Glumerulonephritis (AGN) ASSESMENT Subjective: Nagmamanas ang mukha ng anak ako as vervalized by the patients mother Objective: (+) facial edema BP:90/60 mmHg Temp: 36.8 Weight: 29 Kg NURSING DIAGNOSIS Excess Fluid volume related to failure of regulatory mechanism (inflammation of glomerular membrane inhibiting filtration) evidenced by weight gain, edema, and blood pressure changes PLANNING Short term: After of nursing intervention the patient will demonstrate compliance with dietary and fluid restrictions INTERVENTION 1. Assess fluid status a. Daily weight b. Monitor I & O c. Skin turgor and presence of edema d. BP, PR,RR RATIONALE EVALUATION

2. Limit fluid intake to After nursing intervention prescribe volume and the explain to family the patients blood pressur rationale e will be within normal limits

3. Assist patient to cope with the discomforts resulting from fluid restriction

Assessment provides base Goal met line and ongoing database for monitoring changes and >The patient evaluating interventions demonstrated compliance with dietary and fluid restrictions, Fluid restriction will be blood pressure determined on basis of is within the weight, urine output and normal response to therapy. limit(110/80mmH Understanding promotes g) patient and family cooperation with fluid >Fluid volume is restriction stabilized as manifested by Increasing patient free from signs comfort promotes of edema and vital compliance with dietary signs are in normal restrictions. limit

4. Monitor and record blood pressure as indicated.

Provides objective data for monitoring. Elevated levels may indicate nonadherence to the treatment regimen. These are indications of inadequate control of hypertension and the need to alter therapy.

5. Teach the mother to report signs of fluid overload, vision changes, headaches, edema, or seizures.