University of St.

La Salle
College of Nursing

Nursing Care Plan

Name of Student: Aljean Altheo L. Artillo Section and Group: BN3-B Group 1 (Group 2 RCC)
Name of CI: Marisse Arroyo, RN, MN Area of Exposure: Medical Ward III

Assessment Nursing Diagnosis Rationale/ Goals/ Desired Nursing Rationale Evaluation

Cues Pathophysiologic Outcomes Intervention
Basis

Subjective Cues: Nursing Diagnosis Predisposing After 2-3 days of Independent: Independent: After 2-3 days of
Factor(s): intervention, the -Monitor -Tolerance intervention, the
- Patient Fatigue may be ● 58 years client will be able physiological varies greatly client was able to:
verbalized “I’ve related to old to: response to activity depending on
been having decreased ● Male (changes in BP, the stage of the Short term goals:
some dull, aching metabolic energy ● Filipino Short term goals: heart and respiratory disease ● Relieved
pain in my left production, ● Long-term rate). process, from pain and
lower back. It’s increased energy dialysis ● Report less nutrition state, discomfort as
been going on requirements as ● Weight pain and fluid balance, reported.
now for 3 days. I evidenced by ● History of discomfort. and reaction to ● Show
think that what’s unremitting/ ESRD ● Present therapeutic improvement
remaining of my overwhelming lack ● History of improved regimen. s and
own kidney is of energy, inability substance sense of -Advised patient to -Promotes restored
going bad now.” to maintain usual use, energy. have adequate rest overall health energy.
routines, decreased smoking
-Patient performance, and alcohol -Monitor fluid intake -Assists in Long term goals:
verbalized“I don't impaired ability to consumptio Long term goals: and patient’s fluid maintenance of ● Actively
feel that much. I concentrate, n ● Demonstrat status. fluid participated
am strong but lethargy/ ● Renal e use of requirements in the
sometimes I feel listlessness. Transplanta effective and reduces risk treatment
tired or lack tion coping of harmful side regimen and
energy at all” mechanism effects such as was able to
Precipitating s and hemorrhagic demonstrate
 NANDA Definition: Factor(s): active cystitis in the the use of
Objective Cues: Fatigue is defined ● Lifestyle participatio patient receiving effective
● Patient is as overwhelming ● Diet n in cyclophosphami coping
tensed sustained sense of ● Unmet treatment de (Cytoxan). mechanisms.
and exhaustion and Emotional regimen. ● Performed
worried decreased capacity needs ● Perform -Have patient rate -Helps in ADLs and
● Poor for physical and ● Fear, ADLs and fatigue, using a developing a participated
Appetite mental work at the anxiety, participate numeric scale, if plan for in desired
● Weakness usual level stress in desired possible, and the managing activities at
and signs activities at time of day when it fatigue. level of his
of pain Source/ Nursing level of is most severe. ability.
● Patient Reference: Diagnosis: ability after ● Enumerate
shows Fatigue may be discharge. -Plan care to allow -Frequent rest interventions
fatigue ● Nurse’s related to ● Identify for rest periods. periods and specifically
● Swelling Pocket decreased specific Schedule activities naps are for the
of legs Guide : metabolic energy intervention for periods when the needed to promotion of
and Diagnoses, production, s to patient has the most restore and a healthy
ankles Prioritized increased energy promote energy. Involve the conserve condition.
● Blood in Intervention requirements as healthy patient and SO in energy.
urine s, and evidenced by condition schedule planning. Planning will ● Manifested
● Hemoptysi Rationales unremitting/ ● Present allow the patient normal
s and 14th Edition. overwhelming lack improveme to be active values of
frequent Philadelphia of energy, inability nt in the during times laboratory
coughing , PA: F.A. to maintain usual laboratory when energy and tests
● Patient Doenges, routines, and tests level is higher, results.
has Moorhouse, decreased result. which may
jaundice Murr, 2016. performance, restore a feeling
skin as impaired ability to of well-being
observed ● Nursing concentrate, and a sense of
Diagnosis lethargy/ -Assist with self-care control.
Handbook, listlessness. needs when - Weakness may
Vital Signs: 11th Edition indicated; keep bed make ADLs
BP: 125/73 by Betty J. in low position, difficult to
P: 65 Ackley, Pathophysiology: pathways clear of complete or
RR: 17 MSN, EdS, furniture; assist with place the patient
T: 98.5 F RN, Gail B. The proximal renal ambulation. at risk for injury
 Ladwig, tubular epithelium during activities.
MSN, RN is the kidney tissue -Perform pain
Laboratories: and Mary from which RCC assessment and -Poorly
Abdominal CT Beth Makic, arises. provide pain managed cancer
Scan well PhD, RN, management. pain can
defined, single CCNS, contribute to
irregular, solid 3.5 FAAN, It is considered an fatigue.
inch nodule within FNAP adenocarcinoma. Dependent:
superior pole of -Provide Dependent:
left kidney; left supplemental -Presence of
kidney is oxygen as indicated. anemia and
atrophied from There are two hypoxemia
glomerulonephriti subtypes: sporadic reduces O2
s. Right kidney is (that is, non- available for
normal. Chest X- hereditary) and cellular uptake
ray findings show hereditary. and contributes
that the left lung -Administer iv and to fatigue.
is abnormal with medications as
metastatic prescribed -To relieve pain
disease. Right Both such and discomfort.
lung is normal. subtypes are Collaborative:
Kidney biopsy associated with -Establish realistic Collaborative:
appears large, mutations in the activity goals with -Provides a
pale polygonal short-arm of the patient. sense of control
cells that stains chromosome 3, and feelings of
poorly with eosin. with the implicated accomplishment
Urinalysis genes being either -Provide non-
presence of RBC tumour suppressor pharmacological -.To promote
TNTC high count genes (VHL and comfort measures relaxation, help
of red blood cells TSC) or (massage, refocus
in the urine. oncogenes (like c- repositioning, attention, and
Met). backrub) give comfort to
Strengths: and diversional the patient to
● Patient activities (music, enhance
follows Impaired renal television) communication,
past function coping, and
 treatments expression of
● Cooperate feelings.
s well with
the nurse. Decreased
● Active in metabolic energy
doing production
hobbies.
● Receiving
benefits in
aiding his Inability to do usual
condition. routines

Weaknesses:
● Patient
denies Reference:
some ● https://www
obvious .ncbi.nlm.ni
symptoms h.gov/book
experienc s/NBK4703
ed 36/
● Untreated
mild
recurrent
bouts of
depressio
n
● History of
hyperglyc
emia and
infections.
● Osteoarthr
itis (OA)of
left knee
● Past
history of
renal
 transplant
ation
● Acute
episode of
deep vein
thrombosi
s
● Recent
diagnosed
of peptic
ulcer
● The
patient is
divorced
and lives
alone.
● Unable to
carry out
normal
ADLs
● Non-
complianc
e of
medicatio
ns
● History of
IVDA,
alcohol
use and
cigarette
smoking