 CHAPTER 1

ASSESSMENT

A. Nursing Health History

Personal Data: Baby Ama, 3 years old male who currently resides with his parents at
Paliparan, Dasmarinas, Cavite

Chief Complaint: Facial Edema

History of Present illness: Baby Ama was having a fever five days prior to admission.
Paracetamol drops were taken but did not consult a physician nor went to a health center.
Mother stated that three days prior to admission appearance of facial and periorbital edema
was observed for 3 days as advised by a doctor in Cavite. One day before admission Baby
Ama had a recurrent fever with a temperature of 37.8 °C and progression of the edema,
was prescribed with furosemide and co-amoxiclav. Upon admission of Baby Ama, physical
examination was done. Positive (+) puffy eyelids, symmetrical chest expansion with
negative (-) retractions and clear breath sounds where found. There were no signs of
cyanosis and no murmurs were auscultated. Positive (+) abdominal distention, soft and flat
normoactive bowel sounds (NABS) and negative (-) tenderness was also noted. After
examination, Baby Ama was then admitted at the hospital with an admitting diagnosis of
Acute Glomerulonephritis.

Past Health History: There was no documented illness for Baby Ama except for fever,
cough and cold which were self-medicated and home managed.

Family History: According to the mother of the patient, she has a gallbladder disease and
her husband is a known hypertensive.

Social History: Baby Ama’s family belongs to a poor family of ten. The income of the
family is not enough to provide the basic needs of its members. Father Y is working as an
irregular housing maintenance worker in a company in Pasig and earns only 300 pesos a
day, and Mother Z doesn’t contribute to any financial support due to unemployment.
According to National Economic Developmental Authority (NEDA), a family is
considered a poor family if the income of the family is divided by the number of the
members in the household is less than 2678.60 pesos/ month. The calculated amount of
income of the family is 450.00 pesos/ month in every member of the family. Most of the
income of the family is allotted for food and studies of the children.

Diagnosis: Acute Glumerulonephritis

Complications: End Stage Renal Disease

Gordon's 11 Functional Pattern

a. Health Perception- Health Management

-5 days prior to admission the patient has fever and is relieved by paracetamol. She
immediately had her son checked up at the health center. Three days prior to admission appearance
of facial and periorbital edema was observed for 3 days as advised by a doctor in Cavite. One day
before admission Baby Ama had a recurrent fever with a temperature of 37.8 °C and progression
of the edema with an abdominal circumference of 50 cm. During hospitalization, there is an
increase in abdominal circumference from 50cm-56cm. the patient remains afebrile.

b. Nutritional Metabolic Pattern

- Prior to confinement the pt. weighs 15kg he has a good appetite. He enjoyed eating rice,
fish, meat, eggs and specially junk foods, he also loves soft drinks. During hospitalization the
patient weighs 16kg He still has a good appetite but is on low salt low fat diet and is on limited
fluid intake. He also had an oral lesion in the lips.

c. Elimination Pattern

- Prior to admission the patients void 5-6 times a day while during hospitalization the
patients void 7-8 times a day without any discomfort

d. Activity and Exercise Pattern

-Prior to confinement the patient is playing with his friends outdoors everyday while during
confinement the patient is being restricted to do strenuous activity and is encouraged to rest

e. Sleep Rest Pattern

- Prior to confinement the patient is able to sleep well and is taking naps in the afternoon
while during confinement the patient is still able to sleep well including naps but easily disturb

f. Roles Relationship Pattern

-Prior to admission the patient is living with his family, they have a nuclear type of family
and During hospitalization the patient only have her mother beside him.

B.Physical Examination

Body Parts Actual Findings Analysis

Scalp -clean, free from masses, lumps, Poor hygiene

scars, nits, dandruff and lesions

-no areas of tenderness

-(+) presence of dandruff

Face -rounded, free from wrinkles Due to fluid retention f fluid in

the body
-(+) facial edema
Eyes -brownish,rounded eyes Due to fluid retention n the body
resulting from increase
-(+) periorbital edema hydrostatic pressure
-(-) protrude eyes

Eyelids -puffy eyelids Accompanied by periorbital

edema

Conjunctiva -pale-pink, smooth, shiny Poor tissue perfusion r/t low

hemoglobin counts

Eye movement -limited eye limited Due to periorbital edema,

compression of edematous tissue
on the eyeballs occur

Field of Vision -able to see 90 degree temporary Due to periorbital edema,

compression of edematous tissue
-unable to see 60degree superior on the eyeballs occur
and 70 degree inferior

Lips -thin, pale, smooth and moist Poor tissue perfusion due to low
hemoglobin counts

Gums -pale pink, moist Poor tissue perfusion due to low

hemoglobin level exacerbated to
-no swelling, no discharge facial edema

Teeth -(+) plaque, (-) caries Due to poor hygiene

(+) halitosis

Buccal mucosa -pale, moist, smooth Poor tissue perfusion r/t low
hemoglobin count

Heart Aortic area- no pulsation Due to abdominal distention,

unremarkable apical and
Pulmonic area- no pulsation epigastric area
Apical area- pulsation , not
palpable

Epigastric- not palpable

-no murmur, thrill and heave

Abdomen -skin is unblemished, (+) scars, Scars due to previous wounds

distended
 -umbilicus (concave)position Distention is due to fluid
midway between epigastric and retention
xiphoid process

-color is same as of the

surrounding skin color

-(-)gurgling sound

-percussion reveals presence of

fluid in the stomach and
abdomen

-hard abdomen (-) guarding, no

masses, no area of tenderness

AC: 56 cm

Palpation

-hard abdomen, (-)guarding

Upper Extremities -tan, fine hair evenly distributed Scars due to previous wounds

Arm -warm, dry, (+) scars

Lower extremeties -tan, fine hair evenly distributed Scars due to previous wounds

Legs - (+) scars both legs

-Grade 2 +2 edema

-warm to touch
 CHAPTER 2

THE DISEASE PROCESS

1. Anatomy and Physiology

The body takes nutrients from food and converts them to energy. After the body has taken
the food that it needs, waste products are left behind in the bowel and in the blood. The urinary
systems keep chemicals, such as potassium and sodium, and water in balance, and remove a type
of waste, called urea, from the blood. Urea is produced when foods containing protein, such as
meat, poultry, and certain vegetables, are broken down in the body. Urea is carried in the
bloodstream to the kidneys. Other important functions of the kidneys include blood pressure
regulation, and the production of erythropoietin, which controls red blood cell production in the
bone marrow.

Urinary system parts and their functions:

Two kidneys - a pair of purplish-brown organs located below the ribs toward the middle
of the back. Their function is to:

 Remove liquid waste from the blood in the form of urine.

 Keep a stable balance of salts and other substances in the blood.

 Produce erythropoietin, a hormone that aids the formation of red blood cells.

The kidneys remove urea from the blood through tiny filtering units called nephrons. Each
nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube
called a renal tubule. Urea, together with water and other waste substances, forms the urine as it
passes through the nephrons and down the renal tubules of the kidney.

A rather typical kidney is a compact, bean-shaped organ attached to the dorsal body wall
outside the peritoneum. The ureter leaves the medial side at a depression, the hilum. At this point
a renal vein also leaves the kidney and a renal artery and nerves enter it.

Sagittal section of a human metanephric kidney (semidiagrammatic). (After C. K. Weichert and

W. Presch, Elements of Chordate Anatomy, 4th ed., McGraw-Hill, 1975)

Urinary bladder

A mammalian metanephric tubule, showing the renal corpuscle and secretory and collecting
portions. (After C. K. Weichert and W. Presch, Elements of Chordate Anatomy, 4th ed.,
McGraw-Hill, 1975)

It is a smooth collapsible muscular sac that stores urine temporarily. It is located

retroperitoneally in the pelvis, just posterior to the pubic symphysis. It has three openings. Two
for the ureters and one for the urethra. When the bladder is empty it collapse and its walls are
thick and thrown into folds. The bladder expands and rises into the abdominal cavity as it
accumulates urine. Although urine is formed continuously by the kidney, it is usually stored in
the bladder until its release is convenient.

Ureters
Are slender tubes 25-30 cm long and 6mm in diameter. The superior end of the ureters is
continuous with the pelvis of the kidney and its mucosal lining is continuous with that lining the
renal pelis and the bladder below.
They are passageway of urine from the kidneys to the bladder. They play an active role in
urine transport. They transport urine to the bladder by perstalsis because of the smooth muscle
layers that lines the walls of the ureters.

Two Sphincter muscles

Circular muscles that help keep urine from leaking by closing tightly like a rubber band
around the opening of the bladder.

Urethra
The tube that allows urine to pass outside the body. For female it is about 3-4cm long
whle for male it is approximately 20cm long. It is a thin walled tube that transfers urine
from the bladder to the outside of the body through peristalsis. For males it has two
functions: Passageway of urine to the outside of he body and to carry the sperm in time
of copulation; but these two functions never happen at the same time.

URINE FORMATION
Urine is formed as a result of three processes: Filtration, Tubular reabsorption, and
Tubular secretion.

Filtration
When the blood passes through the glomerulus, it acts as a filter. The filtrate is
essentially blood plasma without the blood protein and blood cells because they are too large to
pass through the filtration membrane.
Tubular Reasorption
The filtrate contains excess water and ions that must be removed from the blood, but it
also contains many useful substances which must be reclaimed from the filtrate and returned to
the blood. Tubular reabsorption begins when the filtrate enters the proximal tubule. Reabsorption
is done passively, like osmosis for water. But reabsorption of the most substances depends on
active transport process (very selective). There are almost no reabsorpton of the nitrogenous
wastes products including urea, uric acid and creatinine, because of this they remain I the filtrate
and found in high concentration in the urine. There is also some reabsorption in the distal tubule
and the collecting duct. The reabsorbed substances are transferred to the extracellular space and
later absorbed by the peritubular capillaries.
Tubular Secretion
Some substances more from the blood of the peritubular capillaries through the tubule
cell or from the tubule ell themselves into the filtrate to be eliminated in he urine. This process
is important for getting rid of substances not already in the filtrate such as certain drugs or as an
additional means of controlling blood PH.

2. Description of the Disease

Glomerulonephritis is a term that encompasses a variety of diseases, most of which is

caused by an immunologic reaction that, in turn, results in proliferative and inflammatory
changes within the glomerular structure
Two forms of glomerulonephritis are included in the category of acute
glomerulonephritis: post-infectious glomerulonephritis and infectious glomerulonephritis. Of the
two, the post-infectious glomerulonephritis, also called acute post-streptococcal
glomerulonephritis, is the most common. (Black, et al, 1993)
A sudden inflammation of the glomerulus is called acute glomerulonephritis. Acute
inflammation of the glomerulus occurs as a result of deposition of antibody-antigen complexes in
the glomerular capillaries. Complexes usually develop 7-10 days after a pharyngeal or skin
streptococcal infection (Corwin, 2008)

Precipitating/Predisposing Factors (Book-based)

Classically, the causative factor is a beta-hemolytic streptococcal infection elsewhere in the
body, although other organisms may be responsible. Typically, it occurs about 21 days after a
respiratory or skin infection. (Black, et al., 1993)
Signs and Symptoms
1. Hematuria – first sign, oliguria and proteinemia (characteristic symptoms)
2. Headache
3. Malaise
4. Fever – initially over 104 F / 40 C; stays at approximately 100 F/ 37.8 C foe duration of
illness
5. Edema – extremities and cerebrum, presents in most patients(characteristic symptom)
6. Hypertension – present in 50% of patients after four or five days
7. Anorexia and vomiting (characteristic symptom)
8. Bradycardia
9. Congestive heart failure
 3. Pathophysiology/Disease Process

Risk factors

Children older than 2 years of age

Boys appear to develop the disease more often than girls

Antigen (group A beta

hemolytic streptococcus

(+) ASO titer Antigen- antibody product (Type III

hypersensitivity reaction) Neutrophil
WBC
segmenters
(11,000/mm3)
count (0.84)

Antigen-antibody complexes form and are being

Activation of cytokines
trapped in the glomeruli

Inflammation ensues; production of Fever

epithelial cells lining the glomerulus
Hematuria
Proteinuria(+2) Permeability of RBC(20-30/hpf)
glomerular membrane
Pus cells 0.50/hpf
Hypoalbuminemia
(protein-59.81,albumin- Tubular reabsorption of
23.68) sodium and water Hgb (9.4),Hct (0.28)&RBC (2.6)

Serum creatinine
(237.4g/l)
Urinary output (505ml)
Periorbital and Abdominal
GFR
facial edema distention

Hypertension
 CHAPTER 3

Nursing and Medical Management

1.Daily Progress Chart

Day of Diet Drugs Tests Activity Treatments Others

admission ( O2, Neb, pertinent
IV and mgt to
others) the
patient
Day 1 -12 - Pen G Pen CBC, PC, - Heplock -
G Na UA,
1,125,000 Creatinine,
U q 6° until C3, ASO
Day 17 Titer,
KUB utz,
Paracetamol TPAG,
400 mg. q 24h Urine
4° ≥38° CHON

Furosemide
10 g. q 12°
decreased
to OD
on April 21,
2009
with BP
prec.
Day 2 -13 Limit Nifedipine - Daily weight - -
fluid 5 mg. SL chart’
intake PRN with abdominal
BP prec. circumference
measurement
Day 3 -14 - - - - - -
Day 4 -15 - - - - -
Day 5 -16 - - - - -
Day 6 -17 - - - - - -
Day 7 -18 - - - - - -
Day 8 -19 - - - - - -
Day 9 -20 - - - - - -
Day 10 -21 - Prednisone - - - -
10 mg/5-6
ml TID
after meals
 Day 11-22 Low Salt - - - - -
Low Fat;
Increase
albumin
diet

Day 12-23 - - - - - -
Day 13 -24 Limit - - - -
Fluid
Intake
Day 14 -25 - - - - - -
Day 15-26 - - - - - -
Day 16-27 - - - - - -
Day 17-28 - - - - - -
Day 18-29 - - - - - -
Day 19-30 - - - - - -
Day 20-1 - - - - - -
Day 21-2 - - - - - -
Day 22-3 - - - - -
Day 23-4 - Albumin - - - -
transfusion

Cefalexin
250 mg/5
ml TID PO

2.Discussion of the specific Nursing and Medical Management

2.1 Diet

Initially patient was advised on Low Salt- Low Fat diet in order to to minimize cholesterol
and fat intake; and to lower body water and promote excretion, specific foods taken includes Fruits,
vegetables, and “natural foods”. Afterwards, the diet was shifted to Albumin diet in order to replace
albumin lost due to the disease process and decrease edema. Specific foods given to patients
includes lean meat, brans, skimmed milk and beef.

2.2 Drugs (following the drug study)

Drugs ( Name, Indication Mechanism of SE/ Adverse Nursing

Classification action Effects consideration
and dosage)

Furosemide Edema Inhibits the Anuria; hepatic Take

Lasix associated with reabsorpton of coma & furosemide as
renal disease. sodium and distal precoma; severe directed by the
Dosage: renal tubules and hypokalemia doctor. Do not
10mg Q 12h the loop of Henle, &/or give it if the
TIV x 3 doses leading to a hyponatremia; systolic
10mg Q 8h TIV sodium-rich hypovolemia pressure is less
diuresis. than 90 mm Hg
 Drug Class: with or without or if the
Loop diuretics hypotension. diastolic
pressure is
greater than
130 mm Hg.

Give early in
the day so that
increased
urination will
not disturb
sleep.

Instruct
patient’s
mother to avoid
prolonged
exposure of the
child to
sunlight
because patient
may have
sensitivity to
sunlight.

Advise
patient’s
mother to
increase
potassium
intake like
bananas, prunes
and orange
juice in the diet.

Weigh patient
on a regular
basis, at the
same time and
in the same
clothing, and
record the
weight to
monitor fluid
changes.

This may cause

dizziness when
standing up so
instruct patient
to take it
slowly.
 Instruct mother
to report if the
patient suffers
dizziness,
prolonged
muscle
weakness, and
fainting.

Penicllin G Treatment of Bactericidal: Contraindicated Make sure that

Sodium severe inhibits synthesis with allergy to the patient has
infections of cell wall of penicillins, no allergy to
caused by sensitive cephalosporis, any penicillin
Dosage: sensitive organisms, causing and other or
1, 125, 000“u” Q organisms – cell death. allergens. cephalosporin
6h TIV streptococci. antibiotics.
375, 000 “u” Q Use cautiously
6h TIV with renal Make sure to
disease. administer the
Drug Class: medication at
Antibiotic regular
Penicillin intervals as
antibiotic instructed and
to continue
therapy even if
patient is
asymptomatic.

These side
effects may
occur: nausea,
vomiting,
diarrhea, mouth
sores, pain at
injection sites.

Report
difficulty of
breathing,
rashes, severe
diarrhea, severe
pain at injection
site, mouth
sores usually
bleeding or
bruising.
Nifedipine Treatment of Inhibits the Contraindicated Make sure that
hypertension movement of with allergy to the patient has
calcium ions across nifedipine no allergy to
Dosage: the membranes of nifedipine.
5mg sublingual cardiac and arterial
muscle cells;
 Drug Class: inhibition of trans- Instruct mother
Calcium channel membrane calcium to put the tablet
– blocker flow results in the under the
Antianginal depression of tongue of the
agent impulse formation patient and
Antihypertensive in specialized make sure that
cardiac pacemaker the patient will
cells, in slowing of not swallow it.
the velocity of
conduction of the Take with food
cardiac impulse, in to avoid nausea
the depression of and stomach
myocardial discomfort.
contractility, and in
the dilation of Monitor
coronary arteries patient’s vital
and arterioles and signs.
peripheral Instruct mother
arterioles; these to avoid giving
effects lead to the patient
decreased cardiac grape fruit
work, decreased juice.
cardiac energy
consumption, and Report irregular
increased delivery heartbeat,
of oxygen to shortness of
myocardial cells. breath, swelling
of the hands or
feet,
pronounced
dizziness,
constipation.

Cephalexin Respiratory Bactericidal: Allergy to Make sure that

tract infection inhibits synthesis cephalosporins the patient is
caused by S. of bacterial cell or penicillins; not
Dosage: pneumoniae, wall, causing cell renal failure. hypersensitive
250 mg/5 ml group A beta – death. to penicillin
TID po hemolytic and
streptococci cephalosporin
Drug Class: antibiotic.
Antibiotic
Cephalosporin Make sure that
(1st generation) the patient will
take the
medication
regularly and
not to miss any
doses.
 Complete the
entire course of
therapy.

Give drug with

or without
meals to avoid
stomach
discomforts.

These side
effects may
occur: stomach
upset; loss of
appetite;
nausea;
diarrhea;
headache;
dizziness.
Report severe
diarrhea with
blood, pus,
mucus; rash or
hives; difficulty
of breathing;
unusual
tiredness;
fatigue; unusual
bleeding or
bruising.

Prednisone Short – term Enters target cells Use cautiously Do not stop
prolix management of and binds to with kidney taking the
primary intracellular disease. drugs without
Dosage: glomerular corticosteroid consulting a
6 ml 3x a day disease receptors, thereby health care
after meals initiating many provider.
complex reactions
6 ml BID after that are responsible Take with
meals for its anti- food.
inflammatory and
10 mg/5 ml BID immunosuppressive Avoid
effects. exposure to
Drug Class: infections.
Corticosteroid
(intermediate Report unusual
acting) weight gain,
Glucocorticoid swelling of the
Hormone extremities,
muscle
weakness,
black or tarry
 stools, fever,
prolonged sore
throat, colds or
other
infections,
worsening of
the disorder for
which the drug
is taken.

2.3 Diagnostic Procedure ( both lab and diagnostics)

Name Date Normal Values Interpretation

of Ordered Values Obtained
Procedure (standard (Results of
of the the test)
hospital )

CBC June 12, 2017 Hgb: 120- Hgb: 100 Low

140g/L

Hct: 0.38-0.45 Hct: 0.30 Low

RBC:4.5- RBC: 3.3 Low

5.6x10^12

WBC WBC: 10.6 High

5.0x10x10/L
Normal
Differential Differential
count: count:

Neutrophil: .63- Neutrophil: 0.32 Low

.65

Lymphocytes: Lymphocytes: High

.20-.35 0.66

CBC June 27, 2017 Hgb: 120- Hgb: 94 Low

140g/L

Hct: 0.38-0.45 Hct: 0.28 Low

RBC:4.5- RBC: 2.6 Low

5.6x10^12
 WBC WBC: 11 High
5.0x10x10/L
Normal
Differential Differential
count: count:

Neutrophil: .63- Neutrophil: 0.84 High

.65

Lymphocytes: Lymphocytes: Low

.20-.35 0.14
Creatinine June 12, 2017 53-97 umol/L 224.2 High
Creatinine June 21, 2017 53-97 umol/L 237.4 High
TPAG July 4, 2017 Total Protein: Total Protein: Low
65-80g/L 59.81

Albumin: 35- Albumin: 23.68 Low

50g/L

Globulin: Up to Globulin: 36.13 High

30g/L
Urinalysis June 13, 2017 Color: straw, Color: Yellow Normal
amber

Character: Character: Slightly Normal

Transparent Slightly cloudy

pH: Acidic pH: Acidic Normal

SG: 1.010-1.025 SG: 1.020 Normal

Sugar: Not Sugar: Not Normal

Present Present

Protein: Not Protein: +1 Abnormal

Present

Pus Cells: 0-1 Pus Cells: 8-12 Abnormal

hpf hpf

RBC: Not RBC: 4-6 hpf Abnormal

Present

Bacteria: Not Bacteria: Abnormal

Present Moderate
ASO June 26, 2017 <200 IU/ml >200 Positive
 24h urine protein June 28, 2017 600-800 ml or 505 ml/ 0.191 Urine protein is
0.1-0.15g/24h g/24h increase

C3 June 28, 2017 0.79-1.67 g/L 1.06 g/L Negative

KUB utz June 20, 2017 Right Kidney: 86.5 x 41.2 x 36.8 mm
Left Kidney: 81.9 x 34.2 x 35.9 mm

Both kidneys are normal in sizes with increased renal

parenchymal echogenicity. No hydronephrosis. No
lithiasis or masses.

The urinary bladder shows anechoic lumen and smooth

wall.

IMPRESSION:
Renal Parenchymal Disease, Bilateral
Normal Urinary Bladder

2.4 Activity / Exercise

Patient is encouraged to ambulate during the entire stay of the hospital.

2.5 Treatment

 Heplock Insertion- in order to have an access to the vein to administer medications

without the IV fluids because the patient is restricted to have an increased fluid intake.

 Daily weight chart- To monitor daily weight if the patient is gaining or loosing body
weight and to anticipate probable complications.

 Abdominal Circumference Measurement- is measured to know if the abdomen is

distended or shrunken in order to anticipate possible complications.
 CHAPTER 4

NURSING CARE PLAN ( THREE PRIORITY PROBLEM)

List of Nursing Diagnosis

Cues NANDA Justification Classification Prioritization

Diet restrictions: Risk for Due to dietary Physiologic 4

Low Salt Low Fat Imbalanced restriction, Baby
diet, Low Potassium Nutrition: less Ama is at risk of
intake, Limit Fluid than body having
Intake requirements imbalanced
nutrition.

Decrease secondary Risk for Infection Due to decreased Physiologic 3

lab values: Hgb, Hct, secondary defense
RBC of the body and
expose to other
patient, Baby
Ama is risk of
having infection
(nosocomial)

Facial and Periorbital Risk for Impaired Due to decrease Physiologic 5

edema; Abdominal Skin Integrity oncotic pressure
distention and increase
hydrostatic
pressure

Periorbital and facial Fluid Volume Due to increase Physiologic 1

edema; Abdominal Excess hydrostatic
distention pressure.

The mother/ SO does Knowledge Deficit Due to deficit of Psychosocial 6

not follow the dietary r/t Ineffective knowledge of the
and fluid restrictions. Therapeutic mother about the
Regimen treatment
management: regimen.
fluid restriction
24’ and dietary
 Puffy eyelids Disturbed Visual Due to periorbital Physiologic 2
Sensory edema there is
Perception disturbed vision.

Cues Nursing Goals Interventions Rationale Evaluation/Outome

Diagnosis
After 2days of Independent After 2days of nursing
Subjective Fluid nursing 1. Note potential 1. Provides intervention the client
Volume intervention source of fluid information will demonstrate
Ang laki-laki ng Excess the client will intake, current regarding the subsided edema from +2
tiyan ng anak ko at related to demonstrate level of ability to tolerate to 0 degree
namamga ang
decreased subsided hydration. fluctuations.
mukha ng anak ko
plasma edema from +2 Goal: Partially Met – due
as verbalized by
the mother of proteins as to 0 degree 2. Assess for 2. To obtain to presence still of
patient. manifested clinical signs of baseline data. edema(facial,periorbital),
by presence After 3 weeks of dehydration or abdominal distention but
Objective of facial, nursing fluid excess. no presence of bipedal
periorbital intervention the edema
>(+)facial edema edema and client will have 3. Maintain 3. To promote fluid
>(+)abdominal abdominal no presence of fluid/sodium management After 3 weeks of nursing
distention distention edema. restrictions. intervention the client
will have no presence of
= 04/13/09 – 50 4. Daily weight 4. To note if there edema.
cm and BP are any changes
monitoring Goal: Not Met – due to
= 05/04/09 – 56 still confinement of the
cm 5. Strict 5.To monitor how patient
monitoring of I much fluid is
> TPAG:
and O retained and loss.
Total
protein:59.81 g/ L

Albumin:23.68 g/ 6. Monitoring of 6. To note

L AC presence or
subsiding
Globulin:36.13 g/ distention of the
L abdomen
Dependent
7. Administer 7. To eliminate fluid
diuretics as excess.
prescribed.
Subjective: Disturbed Short Term
visual After 2days of - Identify - To identify the Short Term
“Hindi makatingin sensory nursing patient appropriate After 2days of nursing
sa taas at baba perception intervention condition that nursing intervention the patient
ang anak ko” as related to the patient will cab affect intervention will manifest the
verbalized by the confining manifest the sensing, following:
patient’s mother illness following: interpreting and >(-) periorbital dema
>(-) periorbital communicating >(-) facial edema
dema stimuli >(-) photosensitivity
Objective: >(-) facial
edema - Note the - To identify the Goal: Partially Met – due
>(+) >(-) severity of extent of visual to the subsiding facial
photosensitivity photosensitivity periorbital disturbances
 edema and and periorbital edma but
>(+) periorbital facial edema (+) abdominal distention
edema Long Term
After 1 week of - Maintain low - To eliminate Long Term
>(+) facial edema nursing salt diet excess fluid After 1 week of nursing
intervention causing edema intervention the patient
>Does not able to the patient will will manifest the
see in all direction manifest the - Provide safety - To prevent following:
following: measures further injury
>Does not able to needed like side >able to see in all
see 60 degrees >able to see in rails, bed in low direction
superiorly, 70 all direction position, and >able to see 60 degrees
degrees inferiorly >able to see 60 adequate superiorly,70 degrees
degrees lighting inferiorly
superiorly,70
degrees - Monitor drug - To identify Goal: Not Met –due to
inferiorly regimen medications with still confinement of the
effects or drug patient
interaction that
may
cause/exacerbate
sensory/perceptual
problems

- Administer - To reduce the

diuretics like severity of edema
furosemide as
ordered

Collaborative:
-Recommend
for -To further check
ophthalmologist the eyes of the
referral patient
A risk diagnosis is Risk for Short Term Independent Short Term
not evidenced by infection After 8hrs of - Stress proper - First line defense After 8hrs of nursing
s/s, as the related to nursing hand hygiene by agalnst healthcare intervention, the
problem has not inadequate intervention, all care givers associated patient’s relative /SO and
occurred and secondary the patient’s between infections (HAI) caregivers will be able
nursing defenses. relative /SO and therapies / identify interventions to
intervention is (decrease caregivers will clients. prevent /reduce the risk
directed at hemoglobin, be able identify for respiratory
prevention. leucopenia) interventions to - Have the - Protection /nosocomial infection
prevent /reduce patient wear a against
Labs: the risk for mask as a nosocomial Goal: Met – Due to the
↓ Hgb : 100g/ respiratory barrier infection verbalization of the
↓ Hct : 0.30g/ /nosocomial protection. patient’s mother about
↓ RBC : 0.6x10g/ infection interventions regarding
↓ Segments : - Monitor nosocomial infection
0.32 Long Term client’s visitor / - To limit control.
↑ Lymphocytes After 3 weeks caregivers for exposures, thus
of nursing respiratory reduce cross- Long Term
interventions illnesses. Offer contamination. After 3 weeks of nursing
,the patient will mask and interventions ,the
manifest tissues to patient will manifest
optimal level of client/visitor optimal level of wellness
wellness and (-) who are
signs of coughing and (-) signs of
nosocomial /sneezing. nosocomial infection
infection
Goal: Not Met – due to
- Instruct in daily - Reduce risk of still confinement of the
mouth care. contamination. At patient and still under
Include use of high risk for medical regimen of the
antiseptic nosocomial / disease
mouth wash for health care
individual in associated
acute/ long term infection.
care setting.

- Provide
Isolation, as - Reduce bacterial
medicated. colonization.
Educate staff in
infection
control
procedures.
 CHAPTER 5

EVALUATION

1. Evaluation of Actual Nursing Problems

Problem Evaluation: Short Term Justification

Risk for Imbalanced Goal: Partially Met Verbalize understanding but

Nutrition: less than body did not take follow the
requirements considerations on food value

- Physiologic

Risk for Infection – Goal: Met Due to the verbalization of

Physiologic the patient’s mother about
interventions regarding
nosocomial infection control.

Risk for Impaired Skin Goal: Partially Met due to still presence of
Integrity - Physiologic edema but subsiding

Fluid Volume Excess – Goal: Partially Met due to presence still of

Physiologic edema(facial, periorbital),
abdominal distention but no
presence of bipedal edema

Knowledge Deficit – Goal: Met due to the verbalization of

Psychosocial the mother of acceptance to
change actions regarding in
achieving health goals

Disturbed Visual Sensory Goal: Partially Met due to the subsiding facial
Perception - Physiologic and periorbital edema but (+)
abdominal distention

Problem Evaluation: Long Term Justification

Risk for Imbalanced

Nutrition: less than body
Goal: Not Met due to still confinement of
requirements
the patient
- Physiologic

Risk for Infection – due to still confinement of

Physiologic the patient and still under
Goal: Not Met
 medical regimen of the
disease

Risk for Impaired Tissue Goal: Not Met. due to still confinement of
Integrity - Physiologic the patient and presence still
of edema

Fluid Volume Excess – Goal: Not Met due to still confinement of

Physiologic the patient

Knowledge Deficit – Mother of the patient did

Psychosocial participate in problem
Goal: Met solving the factors
interfering with integration
of therapeutic regimen

Disturbed Visual Sensory Goal: Not Met due to still confinement of

Perception - Physiologic the patient

2. Proposed Discharge Planning

M– Amoxicillin 125mg/ 5 ml TID 8am-1pm-6pm for 5 days

E– (Exercise) Avoid strenuous activities such as “Habulan” , tumbling and high Jumping.
Avoid games and articles that require fine eye movement.

(Economic) Economic wise they cannot avail the medicines needed

T– Daily weight and AC monitoring

Daily BP monitoring

Monitored intake and output

H– Advised mother to encourage her child to avoid eating junk food.

Advised mother to encourage her child to eat foods rich in carbohydrate

Advised mother to choose foods that are appealing

Advised mother and child to refrain overcrowded places

Advised mother about proper hygiene such as hand washing

Advised mother to weigh her child everyday and have it recorded

Advised mother to keep her child’s back dry always

 Advised mother to have her child’s BP recorded by coming to a health center.

Refer to the nearest Health Center or any health institution when fever, cough (2 weeks),
flank pain, difficulty in urinating, worsening BP, dark brown urine and edema arises.

O– OPD follow-up after 1 week

D– Low Salt, Low Fat diet

High Albumin Intake

Intake of foods rich in potassium