Name: Shyla Nicole C.

Manguiat Date:
09/24/2021
Section: 3BSN-B

Case Scenario
A 12 y.o. student is admitted with dark urine, fever, and headache. Upon assessment, you noted facial
swelling and blood pressure of 140/90. The patient is diagnosed with acute glomerulonephritis. What
will be your plan of care for the patient?

PLANNING
NURSING
ASSESSMENT EVALUATION
DIAGNOSI
GOAL/EXPECTED NURSING INTERVENTION RATIONALE
S
OUTCOME

Subjective: Risk for Patient’s blood Assess patient’s blood Provides Goal Met,
Injury pressure will be pressure, pulse, information the patient
respirations every 4 hours about the results for
- dark urine related to normal within
(monitor BP every 1 hour dangerous effect of
- fever impaired the range of the absence of
if diastolic is more than hypertension which
- headache renal patient. edema and
90, pulse and respirations may result in pulse,
function every 1 hour if and respiration blood
Objectives: Patient will tachycardia, tachypnea, that change pressure
experience an or dyspnea present). with heart within
- facial absence of failure and normal
pulmonary edema. range.
swelling headache and
will appear calm. Assess the changes in Reveals signs and
BP: 140/90 intake and output, extent symptoms
of edema, decreased of possible renal
urinary output, headache, failure.
pallor, electrolyte
balance.

Observe behavior changes It indicates need for

including lethargy,
irritability, restlessness
associated with
hypertension.
safety precautions
associated
with seizure activity
as a result
of cerebral changes.

Encourage the patient to Provides nutrition

eat foods low in sodium,
potassium, and protein
during the acute phase of
AGN; Instruct the patient
to increase intake of food
high in carbohydrates and
fats (only during the acute
phase of AGN), as
prescribe by the doctor.
during the
acute period with
the limitation of
potassium during
oliguria, sodium
with the presence of
edema, protein
limitation if oliguria
is prolonged.

Instruct the patient to This will avoid the

limit fluids as ordered by additional fluid
the doctor; allow intake of retention and
the amount lost via urine edema in the
and insensible losses. presence of renal
damage.
 NURSING PLANNING
ASSESSMENT DIAGNOSIS EVALUATION
GOAL/EXPECTED NURSING INTERVENTION RATIONALE
OUTCOME

Subjective: Excess fluid Patient will Independent: Goal met,

volume gradually patient
- dark urine related to excrete Record the accurate Low output or (less display
- fever excessive fluid intake and output of the than 400ml/24hr) is
decrease in appropriate
- headache through patient. the first indicator of
regulatory urination. acute renal failure. urinary
mechanisms output with
Objectives:
as Patient will Monitor urine specific To measure the normal
evidenced demonstrate gravity. kidney’s ability to specific
- facial
by puffiness behaviors that concentrate urine. gravity and
swelling
in the face. would help in laboratory
excreting Weigh the patient daily Daily body weight is
BP: 140/90 status within
excessive fluids at the same time of the the best to monitor
in the body as day. the fluid status, normal
manifested by also, Also a weight range.
the absence of gain of more than
edema. 0.5kg/day may
suggest fluid
retention.

Monitor the heart rate Tachycardia and

and blood pressure of the hypertension can
patient. occur because of
failure of the kidney
to excrete urine.

Elevate patient’s To promote venous

edematous body part return.

Collaborative:

Monitor serum sodium. Hyponatremia may

result from fluid
overload or kidney’s
inability to conserve
sodium,
(hypernatremia
indicates total body
water deficits)

Monitor serum Lack of renal

potassium. excretion and
selective retention
of potassium to
excrete excess
hydrogen ions lead
to hyperkalemia
requiring prompt
treatment.

Administer diuretics. To promote

adequate urine
volume.