ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING RATIONALE EVALUATION

PROBLEM
Subjective:
“maululawak garod
sagpaminsan ken kasla
agpipikel ti ramay ko ken di
ak unay makaisbo”
Objective:
 Increase in BUN,
Creatinine, Uric
Acid Level
 Hypertension
 Pulmonary
Congestion
 Hematuria
 Oliguria
 Anuria
Nursing Diagnosis:
Altered Renal Tissue
Perfusion related to
Glomerular Malfunction as
evidenced by Increase in
BUN, Creatinine and Uric
Acid level
INTERVENTIONS
For optimal cell functioning
the kidney excrete
potentially harmful
nitrogenous product-Urea,
Creatinine, Uric Acid but
because of the loss of
kidney excretory functions
there is impaired excretion
of nitrogenous waste
product causing in increase
in Laboratory result of
BUN, Creatinine, Uric Acid
Level
STO: Within 4 hour of Dx:
effective nursing  Assessed the general
interventions, the patient condition and
will be able to: monitored vital signs.
 Assessed patient
 Verbalized emotional/psychologica
understanding of l factors affecting the
risk factors or current situation
condition, therapy
regimen, side effect
of medications, and  Noted mentation status
when to contact and review lab result
health provider. such as BUN and
creatinine levels.
 Demonstrate  Noted characteristics of
participation in his urine: measure urine
recommended specific gravity
treatment program.
Tx:
 Established rapport
LTO: Within 3 days of
effective nursing
interventions, the patient  Provided diet restriction
will be able to: as indicated, while
providing adequate
 Demonstrate calories.
behavior/lifestyle  Provided physiological
changes to prevent support. Maintained
complications calm attitude but admit
concerns if questioned
by the client/SO.
 Administered
medication as ordered.
Dx: STO:
 To obtain baseline data. Goal Met
After 4 hour of effective
nursing intervention the
 Stress or depression client understand the risk
may be increasing the factors or condition when to
effect of an illness or contact health care provider
depression might be the and he demonstrated
result of being forced participation on
into inactivity. recommended treatment
 Increase BUN and program.
Creatinine levels may
alter mentation LTO:
Goal Met
 To assess for hematuria After 3 days of effective
and proteinuria and nursing intervention the
renal. patient demonstrated
behavior changes to prevent
complication
Tx:
 To get the cooperation
of the patient.
 Calories to meet body’s
need while restriction of
protein helps limit
BUN.
 Honestly can be
reassuring when so
much activity or worries
are apparent to the
client or SO.
 For faster recovery. It is
used to treat the client’s
disease condition.
 Promoted overall health  To promote wellness.
measure.
Edx:
Edx:  To provide opportunity
 Educated client/SO in for timely evaluation
reportable symptoms, and intervention.
including any changes
in pain level, difficulty
walking nonhealing
wounds.
 Emphasized need for  To evaluate disease
regular medical and progression and
laboratory follow-up. response to therapies.
 Encouraged discussion  To decrease anxiety
of feelings regarding about condition and
prognosis or long-term correct his wrong ideas
effect of discussion. about condition.
 Encouraged to maintain  To enhance sense of
positive attitude; well-being.
suggest use of
relaxation technique
such as guided imagery
as appropriate.
 Assessment Explanation of the
Problem
Objective: Alterations in the immune
 Hyperthermia system that occur with
 Low Bicarbonate chronic kidney dysfunction
 Elevated WBC are associated with increased
susceptibility to infections
 Increase ammonia
and poor vaccine response.
and Urea Metabolic acidosis reflects
an excess of acid (hydrogen)
Nursing Diagnosis: and a deficit of base
Risk for infection related
(bicarbonate) resulting from
to metabolic acidosis
acid overproduction, loss of
intestinal bicarbonate,
inadequate conservation of
bicarbonate, and excretion of
acid, or anaerobic
metabolism.
Objectives Nursing Interventions Rationale Evaluation
STO: Dx: STO:
After 1 hour of nursing  Assessed causative contributing  Personal habits or living situations Goal Met
intervention, the patient will: factors. can increase susceptibility to Within 1 hour of effective
 Verbalize understanding infection. nursing interventions, the
of individual causative or patient is afebrile and was
risk factors.  These represent a break in the able to verbalized
understanding causative
 Identify interventions to  Assessed for the presence, body’s normal first line of defense.
prevent or reduce risk of existence of, and history of risk factors and identify to
infection. prevent infection.
factors such as sufficient
 Be afebrile
knowledge to avoid exposure to
pathogens which related to tissue LTO:
LTO:
trauma. Partially Met
After 8 hours of effective
nursing intervention, the After 8 hours of effective
patient will:  Assessed la results for infection  To prevent and treat an infection. nursing intervention, the
 Demonstrate (elevated WBC and positive patient demonstrate
techniques, lifestyle blood cultures). lifestyle changes to
promote safe environment.
change to promote
safe environment  Assessed temperature,  Provides information about the
 be free from signs and respiratory and urinary system presence of infection caused by
symptoms related to changes as the disease progressive chronic disease and its
infection. progresses. deteriorating effect on all systems.
Tx:
 Reduce existing risk factors.
Tx:
 Provided clean, well ventilated
environment.
 Aseptic technique decrease
 Maintained aseptic technique for changes of transmission or
dressing changes and wound
 care.
 Performed daily mouth care.
Include use of antiseptic
mouthwash for individuals in
acute or long-term care settings.
 Administered antibiotic therapy
as ordered
Edx:
 Emphasized necessity of taking
antibiotics as directed if infection
occurs. Instruct to take the well
course of antibiotics even if
symptoms improve or unnoticed.
 Recommended to increase intake
of foods rich in vitamin C from
raw fruits and vegetables.
 Taught the patient and/or
significant other to wash hands
often, especially after toileting,
before meals, and before and
after administering self-care.
spreading pathogens to the patient.
 At high risk for nosocomial or
HAIs.
 Prevents or treat an infection.
Edx:
 Antibiotic works best when a
constant blood level is maintained
which is done when medication
are taken as prescribed. Not
completing the regimen can lead to
drug resistance in the pathogens
and reactivation of symptoms.
 It increases the immune system in
fighting for possible infectious
microorganisms.
 Patients and significant other can
spread infection from one part of
the body to another – handwashing
reduces these risks.