Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired Urinary Short term: Independent: Short term:

No subjective cues Elimination R/T
failing glomerular After 8hrs of nursing •Determine • To assess Goal not met
Objective: filtration AEB intervention the patient clients pattern of degree of
increase in lab will demonstrate elimination interference. After 8hrs of
• Increase in results (BUN, improvement in urine nursing
Lab results Creatinine) elimination. •Palpate bladder • To assess intervention the
(BUN, Anuria, Peripheral retention patient will able to
Creatinine) edema (+2) in left Long Term: demonstrate
• Anuria arm and left leg •Determine • To help improvement in
• With After 3 days nursing client’s usual determine level urine elimination.
Indwelling intervention the patient daily fluid intake of hydration
Foley will have decreased Long term:
Catheter peripheral edema of 1+ •Emphasize the • To prevent
• Peripheral or less within 72 hours need to adhere aggravation of Goal Met
edema (+2) or 3 days. with prescribe disease
in left arm diet (Ex. Limit condition. After 3days of
and left leg Fluid Intake to < nursing
1L/ day intervention the
patient will have
•Emphasize • To promote decreased
importance of wellness peripheral edema
adhering to of 1+ or less
treatment within 72 hours or
regimen 3 days.

Dependent:

•
Collaboration:

• Provide diet • Calories to meet

restriction as body’s need while
dietitian restriction of
prescribe (low protein helps limit
salt, low fat), BUN.
while providing
adequate
calories.
• Diuretics to
• Administered remove
meds by doctors excessive fluids.
order (e.g.
furosemide)