ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE Risk for decreased SHORT TERM INDEPENDENT: INDEPENDENT: SHORT TERM
DATA: cardiac output GOAL: 1. Define and 1. Provide the GOAL:
Patient stated that After 1 hour of specify the basis for After 1 hour pf
sshe nursing desired blood pressure understanding blood nursing
have intervention, The limit. pressure elevations intervention, The
hypertension patient was able to Explain the effects of and clarify that high patient was able to
since verbally hypertension on the blood pressure can verbally
10years. demonstrate an heart, blood vessels, exist without demonstrate that
cardiac output awareness of the kidneys, and brain. symptoms or even they were aware of
disease process as when an individual the therapy regimen
well as the 2. Monitor the feels healthy. as well as the
OBJECTIVE treatment schedule. patient for the signs and 2. Chronic disease process.
DATA: symptoms of kidney disease may SHORT TERM
T:37c hypertension or high be the root cause of GOAL MET
P: 95 LONG TERM blood pressure. any and all signs and
R: 20 GOAL: symptoms.
Bp: 140/90 After 24 hours of DEPENDENT: DEPENDENT:
nursing 3. Advise the 3. To assist in the LONG TERM
intervention, The patient to limit control and GOAL:
patient will be able consumption of sodium- maintenance of blood After 24 hours of
to keep track of and cholesterol-rich pressure within a nursing
their status and take foods. range that is intervention, The
measures that will considered patient will be able
be beneficial to COLLABORATIVE: appropriate. to monitor their
their health. 4. Check the COLLABORATIVE: own status and take
patient's medication 4. A patient's measures that will
history and look for tolerance to pain lead to an
signs of substance medication may improvement in
abuse increase if they have their health.
. a history of substance LONG TERM
abuse. GOAL MET
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE: EVALUATION
 SUBJECTIVE Fluid Volume SHORT TERM 1. Establish 1. Establish SHORT TERM
DATA: Excess related GOAL: rapport. rapport. GOAL:
" Namamaga to sodium After 2 hours of After 2 hours of
ang mga binti retention nursing 2. Monitor and 2. Monitor and nursing intervention
at paa ko" as As manifested intervention patient record vital signs. record vital patient is able to
verbalized by by the is able to take the signs. take the appropriate
the patient presence of necessary measures 3. Compare current actions or steps to
edema in or steps to prevent weight gain with 3. Compare prevent and reduce
OBJECTIVE both lower and reduce an admission or current weight an excessive
DATA: extremities. excessive amount previous gain with amount of fluid
Presence of of fluid volume. stated. admission or volume. patient has
edema in  Minimize previous the ability to
both lower presence of edema 4. Weight daily stated. perform these
extremities.  Achieve every morning actions and
Vitals signs: stable weight in same clothes. 4. Weight daily activities.
Bp: 140/90 and stable vital every morning  Absence of
PR: 95 5. Discuss the in same edema and body
signs.
RR: 20 following clothes. weight return to
T: 37 °C LONG TERM measures to normal.
GOAL: prevent and 5. This Prevent and  Vitals sign
After 3 hours of reduce excessive reduce lower within the
nursing fluid volume: extremity fluid normal range
intervention a)Advise the patient accumulation SHORT TERM
sthe patient will to elevate their feet b)Sodium GOAL MET
show no visible when seated consumption
symptoms of b)Instruct the patient induces a sensation LONG TERM
edema. to limit their sodium of thirst. This GOAL:
intake causes an increase After 3 hours of
 Prevent the in fluid intake. nursing intervention
diseases' the patient doesn’t
complication have symptoms of
edema and prevents
complications of
 disease.
LONG TERM
GOAL MET

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

 SUBJECTIVE Discomfort back SHORT TERM 1.Using a pain 1. An evaluation of SHORT TERM
DATA: pain GOAL: rating scale, pain can yield GOAL:
Patient state that as evidenced After 1 hour of determine the information that After 1 hour of
her kidney nursing character of the is helpful in nursing intervention
back is in pain failure related to intervention the pain, its location, making a the patient
Objective: chronic kidney patient may its severity, and diagnosis and experienced relief
Presence of edema disease experience relief how long it lasts. can be utilized to from a back pain.
in from backache establish SHORT TERM
both 2.Have the patient whether or not GOAL MET
lower LONG TERM sit down and place treatment is
extremities GOAL: a pillow behind necessary. LONG TERM
After 24 hours of her back as you GOAL:
OBJECTIVE nursing evaluate her 2. To make the After 24hours of
DATA: intervention the condition. patient more nursing intervention
T: 37 C patient's back comfortable in and encouraging
P: 95 discomfort subsides 3. An acceptable their back. the patient, the
R: 20 after 24 hours of description of the patient showed
BP: 140/90 encouragement to client's discomfort. 3. Pain is a personal interest and
engage in physical Acknowledge the experience that motivation to
activity for chronic client's sense of pain cannot be conveyed engage in physical
kidney disease. and let them know through activity for chronic
that you accept their instructions. kidney disease.
reaction to the LONG TERM
suffering. GOAL MET

DISCHARGE PLANNING

MEDICATION:
 Explain to the patient the significance of taking their medications at the prescribed times.
  The health care provider should urge the patient to take the prescription exactly as prescribed by the medical professional.
 Offer the patient any further information you have or just a friendly reminder regarding their medication use.

ENVIRONMENT:
Emphasize the importance of the acronym KIDNEY

K-keep administer medication as indicated

I-Improve sleep habits
D-Discuss the possible risk of the disease
N-Never take a medicine less often or take a smaller dose
E-Encourage the family of the patient to monitor the patient blood pressure
Y-You work with a dietitian to develop a meal plan

APPOINTMENT:
 Inform the patient of the need to attend follow-up appointments in order to comply with the recommended medical and
laboratory follow-ups.
 Follow-up check-up

HEALTH TEACHING:
 Encourage the patient to make dietary changes in order to control or avoid some of the complications of chronic kidney
disease. A healthy, well-balanced diet can help you improve your overall health and lower your risk of developing new
problems. -Consume the appropriate amount and type of protein.
 Choose foods that are good for your heart.
 Either stop smoking or don't start. Smoking can aggravate kidney disease and interfere with blood pressure medication.

SPIRITUAL ADVICE/MOTIVATION:
 Encourage the patient to attend church services so that she can meet her spiritual needs and never give up no matter what
challenges he/she faces.