Table 20.
Shows the ten day monitoring chart of the responses made by the client to the nursing interventions rendered integrating
NURSING DIAGNOSIS Day 1
Imbalanced nutrition:  Initial interaction with
less than body the client made.
requirements related to  Assessment done
dietary restrictions utilizing Henderson’s
Components health
assessment tool.
 Client had pandesal and
coffee for breakfast.
 He ate curls and drank
soda for snacks while
he is ongoing dialysis
session.
 Client’s :
Weight: 51kg
Height: 5’3”
BMI: 19.9 (underweight)
Day 6
 Client is aware of the
importance of food
groups in every meal.
 Had a cup of rice and
chicken adobo for
71
Virginia Henderson’s Theory.
Progress Notes
Day 2 Day 3 Day 4 Day 5
 Client considered eating  Client tolerated eating  Client weight is  Client had sunny
light breakfast which rice with fried fish and a schedule for dialysis side-up egg and tuna
consisted of 3 pieces of slice of mango for session. sandwich for
pandesal and a cup of breakfast.  Weight is 57.5 kg. breakfast.
coffee.  Client included cooked  Client had a cup of  Had rice and fish
 Encourage to avoid vegetables for lunch rice and steamed fish soup for lunch.
drinking coffee and aside from fried fish. for breakfast.  Ensaymada bread and
carbonated beverages.  Had chicken soup for  Ate chicken sandwich a glass of mango
 Included 1 small slice dinner. for snacks while juice for his afternoon
of fried fish for lunch  Snacks in between were ongoing dialysis snacks.
and dinner. chicken sandwich. session.  Had sotanghon for
 Encourage to eat meals  Client verbalized he dinner.
according to basic food avoids coffee and
groups. carbonated beverages.
 Client is aware of the
oral fluid intake
limitations.
 Took chicken adobo
for lunch.
 Dinner comprised of
grilled fish and a sliced
of mango.
Day 7 Day 8 Day 9 Day 10
 Client had a cup of rice  Client is schedule for  Client had a cup of  Weight gain of 0.9
and fried fish and a slice dialysis session again. rice and fried chicken from previous weight.
of mango for his  Weight of 54 kg. for breakfast. He also  Client had a cup of
breakfast.  Client verbalized he includes a slice of rice, fried fish and
 Client totally stops from stop having coffee mango for his meal. egg for breakfast.
 breakfast. drinking carbonated
 Snack in between were beverages.
skyflakes and a water.  Took egg sandwich and
 Client had a cup of rice water for snack.
and fish soup for lunch.  Client had a cup of rice
 Client had a grilled fish and vegetable soup for
and a cup of rice for lunch.
dinner.  Ate grilled chicken, a
cup of rice and a slice
of mango for dinner.
during breakfast.  His lunch consisted of  Had sautéed fish, a
 Client had a cup of rice, pinakbet, a cup of rice cup of rice and a slice
fried fish and a slice of and a glass of mango of mango for lunch.
papaya for breakfast. juice.  Client ate chicken
 Took a macaroons and a  Had chicken sandwich sandwich and a glass
glass of water as snack and a glass of water of water for afternoon
while in ongoing for afternoon snack. snack.
dialysis session.  Client had chicken  Client had grilled
 Verbalized the soup, a cup of rice and fish, a cup of rice and
importance of having 3 slice of mango for a slice of mango for
meals a day. dinner. dinner.
 Had a spaghetti pasta  Client is now totally
and a glass of water for aware of importance
lunch. of having 3 meals and
 Client had grilled fish the basic food groups.
and a cup of rice for  Aware of his fluid
dinner. intake limitations.
 Terminated contact
with the client.

NURSING DIAGNOSIS Day 1 Day 2 Day 3 Day 4 Day 5

Fluid Volume , excess  Initial interaction with
related to Compromised the client made.
Regulatory Mechanisms  Assessment done
(Chronic Kidney utilizing Henderson’s
Disease) Components assessment
tool.
 Vital signs taken,
height, weight and were
documented.
 With mild bipedal
edema.
 Instructed to limit oral
fluid intake to 1 to 1.5
liters per day.
 The client’s weight and  Discussed eating habits,
vital signs taken for
monitoring.
 Assessed client for
edema and other signs
of fluid overload.
 Client has mild bipedal
edema.
 Assessed factors that
may cause fluid
overload like diet.
 The client is again  Conducted health
including food schedule for dialysis. teaching about fluid
preferences. His weight is 57.5 kg volume overload. The
client was very
weight gain from
attentive and had
previous dialysis some queries about
session post weight is the causes and the
3.5kg. relation to his
 Assessed client for condition, and how to
edema and other signs avoid excess fluid.
of fluid overload.
 Client has mild bipedal
edema.
 Assessed factors that
may cause fluid
overload like diet.

72
  Advised about limiting
his food and fluid
intake, and to limit
consuming fast food or
junk food.
Day 6 Day 7 Day 8 Day 9 Day 10

 Encouraged client to  Provided list of food to  The client schedule for
avoid salty foods and eat and to avoid. dialysis. His weight
other food that may  Provided information prior to dialysis is 54 kg
cause fluid retention regarding nutritional with weight gain of 2 kg
which lead to excess needs and ways to meet from previous post
fluid. this needs within the dialysis weight
prescribed diet for  Client verbalizes
ESRD patient. understanding on the
important of following
prescribed diet, like
limiting salty food and
limiting fluid.
 The client understands
the effects of excess
fluid to his current
condition.
 The client verbalizes  Re-assessed patient
he is limiting his for any sign of fluid
intake of food overload.
especially salty food  Evaluate progress.
and fluid intake.  Client weight gained
is between 0.9kg
from previous weight.
No signs of edema,
no crackles heard
from the lungs upon
auscultation, no
distention of neck
vein and with normal
skin turgor.
Terminated contact
with client.

NURSING DIAGNOSIS Day 1 Day 2 Day 3 Day 4 Day 5

Impaired physical  Established  Client’s behavior is  Client recognized  Client has  Client assured
mobility related to pain guidelines and the same with Day energy limitations. accepted his safety when
on both knees goals of activity 1 but with the  Client can encouragement transferring him
with the patient. acknowledgement established regular and aid with from any
that change is not activities. dressing as position.
that easy to do. needed.

73
 Day 6
 Client verbalized
that constant
practice of new
habits may help
him in mastering
the art of actually
doing them without
constant reminder.
NURSING DIAGNOSIS Day 1
Fatigue related to  Initial interaction with  Monitored client’s
anemia and dialysis the client made.
procedure  Client verbalized
weakness and lack of  Client sometimes
energy.
 Inability to perform
ADLs at normal rate
Day 6
74
Day 7 Day 8
 Client prioritized  Client can assessed
activity to do for and noted his prior
the day to balance and present
it with rest that he activities when
will allot for today. transferring from
any position.
Day 2 Day 3
 Client behavior is the
response to ADLs and same with the previous
other activities at home. day but with eagerness
to change.
recognize energy  Identified with the
limitations and client activities that
sometimes reports cause his fatigue.
endurance of activity.
Day 7 Day 8
Day 9 Day 10
 Client can  Client achieved
perform self-care the highest level
measures of independence.
depending on his
ability
Day 4 Day 5
 The client is schedule  Client continuously
for his dialysis balanced activity with
session. rest.
 Client with the desire  Napped anytime of
to change started to the day as long as
balance activity with client feels sleepy.
rest.  Used conservation
 He started to take techniques and adapts
naps, use conservation lifestyle to his energy
techniques. level.
 Client was already  Encourage client to
recognizing his energy do whatever possible.
limitations.  Health teaching on
 Client enumerates fatigue management
activities he enjoys done.
and deemed
meaningful to him.
 Encourage adequate
nutrition and fluid
intake.
Day 9 Day 10
  Planned with the client  Client prioritized  Client is schedule again  Unfailingly  Client had been active
and significant others activity to do for the for his dialysis session. demonstrated balance physically and able to
schedule to allow day to balance it with  Client consistently in activity and rest. manage to balance his
adequate rest periods. the rest that he will demonstrate balance in  Acknowledge his own activity and rest.
 Client expressed allot for today. activity and rest. energy limitation,  Naps had started to be
compliance to energy-  Conservation  Organized his own adapting his energy to client’s habit. He
conserving techniques techniques were used. activities for the day to the lifestyle that he verbalized it help it
such as walking as a  Noticed that the client conserve energy. has. increase his energy
form exercise and was able to perform  Activities such as level.
having adequate more activities and walking and doing  Client has been
nutrition. chores at a slower pace. simple household constantly aware of
chores can already be the activities that are
mange by the client. not already within his
 Client verbalized limits.
tolerance to most  Terminated contact
activities. with client.

NURSING DIAGNOSIS Day 1 Day 2 Day 3 Day 4 Day 5

Disturbed sleep pattern  Initial interaction with
related to unresolved the client made.
psychological conflict  Assessment done
utilizing Henderson’s
Components health
assessment tool.
 Client was aware of the
anxiety he felt yet did
not monitor it intensity.
 Client was able to  Verbalized the need to  Client is for his  Client started to
maintain adequate monitor intensity of dialysis session. monitor intensity of
sleep. anxiety.  Client verbalized that anxiety.
 Experienced easy  Client sought listening to his favorite  Client also distressed
fatigability when he information to decrease songs helped to keep through watching TV
does not have enough anxiety. him calm. and reading
sleep.  Client and nurse  The following were magazines.
 Often, the client was together planned coping already often  Client participate in
moody when he lacked strategies for stressful demonstrated by the the discussion in

75
  Rarely decreased sleep. situations. client: seeking search for
environmental stimuli  Client still did not  Nurse demonstrated information to information to lessen
when anxious. monitor duration of relaxation techniques decrease anxiety, anxiety.
 The following were anxiety episodes. such as imagery and planning coping  Planned with us
sometimes  Although client was breathing exercises to strategies for stressful coping strategies for
demonstrated: seeking under anxiety, he still reduce anxiety. situations, using stressful situations.
information to decrease maintained her role as a  Client remembered that effective coping Including the patient
anxiety, planning person and maintained anxiety episodes should strategies, using in the planning phase
coping strategies for her relationship with be monitored. relaxation techniques encourage good
stressful situations, other people.  Number of hours of to reduce anxiety. compliance.
using effective coping  Number of hours of sleep= 4-5 hours.  When client lacked of  Number of hours of
strategies, using sleep 4hours. sleep he verbalized he sleep= 5 hours.
relaxation techniques to had less concentration
reduce anxiety. especially when doing
 Number of hours of something.
sleep 4 hours.  Client started to regain
concentration every
time she feels stressed.
 Number of hours of
sleep= 4-5hours.
Day 6 Day 7 Day 8 Day 9 Day 10

 Client sought  Client verbalized that he  Client is schedule for  The following were  Unaware of the
information to decrease continued listening to dialysis session again. constantly duration of episodes
anxiety. his favorite song,  Client started to regain demonstrated by the as client does not
 Client continued to plan watching TV and concentration every client: monitors monitor them at first.
with us coping reading magazines help time he feels stressed. intensity of anxiety, Upon discussing
strategies to use for him keep calm.  Client verbalized that decreases things over, client
stressful situations.  Taking naps help the techniques such as environmental stimuli already monitored
 Relaxation techniques client to avoid breathing exercise, when anxious, seek duration of anxiety
such as breathing fatigability and its listening to mellow information to reduce episodes and reports
exercise were increase his energy music contributed to anxiety, plans coping shorter episodes after
demonstrated by the level. reducing anxiety that he strategies for stressful 10 days care.
client.  Along with the physical feels. situations, uses  Client still maintained
 Client still maintained manifestations, client  Client was already able effective coping his role as a person
his role as a person. also monitored to increase her usual strategies, uses and his relationship
 His anxiety did not behavioral number of hours of relaxation techniques with other people was
affect his relationship manifestations of sleep. to reduce anxiety, not affected.
with other people. anxiety.  Number of hours of controls anxiety  The client has
response.

76
  Number of hours of  Number of hours of sleep= 5-6 hours.  Client continuously
sleep= 5 hours. sleep= 5.5 hours. participate in the
discussion in search
for information to
lessen anxiety.
 Number of hours of
sleep= 5-6 hours.
 Client’s number of
 Terminated contact
77
achieved optimal
amount of sleep with
the use of anxiety
self-control measures
as evidence by rested
appearance,
verbalization of
feeling rested and
improvement in sleep
pattern.
hour sleep has
increased from her
typical 4-5 hour of
sleep to 5-6 hour of
sleep. Client was also
able to take naps
during the day.
with the client.