SAN SEBASTIAN COLLEGE - RECOLETOS DE CAVITE INC.

COLLEGE OF NURSING
Sta. Cruz, Cavite City

NURSING CARE PLAN

Name: Kevin Kier Barias Age: 16 years old Home Address: Brgy. 3526 San Francisco, General Trias, Cavite Admitting Diagnosis: Acute Glomerulonephritis Assessment
Subjective: namamaga po ang muka ko . As verbalized by the client. Objective: - Restlessness - Puffy face - Input: 520 - Output: 200

Sex: Male

Civil Status: Single Date Admitted: June 18, 2011 Final Diagnosis: Acute Glomerulonephritis Intervention Rationale Evaluation
- Goals met. After 8 hours of nursing intervention the patient became free from edema. - Goals not met. After 2 days of nursing intervention the patient does not stabilize fluid volume.

Nursing Diagnosis
Excess fluid volume related to failure of regulatory mechanism.

Background Knowledge
Unhealthy life style Invasion of streptoccocus inflammation of glomerular membrane inhibiting filtration Edema

Expected Outcome
Short term goal: -After 8 hours of nursing interventions the patient will be free from edema. Long term goal: -After 2 days of nursing intervention the patient will stabilized fluid volume as evidenced by balanced input and output.

Pdx: -monitored vital signs. -monitor input and output. Prx: - asked patient to limit fluid intake. - Fluid restriction will determine on basis of urine output and response to therapy. -increasing patient comfort promotes compliance with dietary restrictions. -for base line data. - for baseline data

- assisted patient to cope with the discomforts resulting from fluid limiting.

- Identified potential sources of fluid such as medication orally and intravenously and fluids used to take. Ped: - encouraged frequent oral hygiene

- Unrecognized sources of excess fluids may be identified.

- Oral hygiene minimizes dryness of oral mucous membranes. -indicates need for prompt intervention. -to have enough rest.

-review sign and symptoms of acute glomerulonephritis. -provide quiet environment.

Prepared by: Group 1 BSN4A Date Submitted: June 29, 2011

Submitted to: Ms. Mary Jochen Salvador

SAN SEBASTIAN COLLEGE - RECOLETOS DE CAVITE INC. COLLEGE OF NURSING

Sta. Cruz, Cavite City

NURSING CARE PLAN

Name: Kevin Kier Barias Age: 16 years old Home Address: Brgy. 3526 San Francisco, General Trias, Cavite Admitting Diagnosis: Acute Glomerulonephritis Assessment
Subjective: Nauuhaw po ako. As verbalized by the client. Objective: - Restlessness - Dry lips - Input: 520 - Output: 200

Sex: Male

Civil Status: Single Date Admitted: June 18, 2011 Final Diagnosis: Acute Glomerulonephritis Intervention Rationale Evaluation
- Goals met. After 8 hours of nursing intervention the patient verbalized understanding of limitation in fluid intake. Goals partially met.

Nursing Diagnosis
Imbalanced nutrition less than body requirements related to dietary restrictions.

Background Knowledge
Inflammation of glomerular membrane inhibiting filtration

Expected Outcome
Short term goal: -After 8 hours of nursing interventions the patient will verbalize understanding of individual fluid restrictions. Long term goal: -After 1 day of nursing intervention the patient will only have 1,600ml fluid intake as prescribed by the physician.

Pdx: -monitored vital signs. -monitor input and output. Prx: - assessed patients nutritional dietary patterns such as diet history and food preferences. - Past and present dietary patterns are considered in planning meals. -for base line data.

- for baseline data

limited fluid intake Imbalanced nutrition

- assisted patient to

-increasing patient

cope with the discomforts resulting from fluid limiting intake. - encouraged frequent oral hygiene

comfort promotes compliance with dietary restrictions.

- Oral hygiene minimizes dryness of oral mucous membranes. -he lps determine nutritional needs.

-noted age, body build, activity and rest level. Ped: - explained to patient and family the rationale for fluid limiting.

- Understanding promotes patient and family cooperation with fluid limiting. -indicates need for prompt intervention. -to have enough rest.

-review sign and symptoms of acute glomerulonephritis. -provide quiet environment.

Prepared by: Group 1 BSN4A Date Submitted: June 29, 2011

Submitted to: Ms. Mary Jochen Salvador