Name: De Jesus, Fatima Kate M.

Date: September 19, 2023

Course & Year level: BS Nursing III Submitted to: Mr. Mikel Renz Cariño, RN

SOAPIE
Patient’s name: Villegas, Izarwin D. Room: 308
Age: 6 years old Case: Acute glomerulonephritis

SUBJECTIVE OBJECTIVE ASSESMENT PLANNING INTERVENTIONS EVALUATION

SUBJECTIVE: OBJECTIVE: - Excess fluid Short term goals: Monitor vital signs every 4 hours Short term:
The mother - Periorbital volume may be Goals are met after
verbalizes: edema related to After 3 hours thorough R: An assessment provides 3 hours of
failure of nursing intervention, baseline information for monitoring thorough
-“Nagmamanas - Dependent regulatory the patient will be able changes and evaluating the Nursing
ang mga paa at edema mechanism to; effectiveness of therapy. intervention, the
ilalim ng mata (inflammation patient was be able
ng anak ko” - BP: 110/90 of glomerular a) Gradually excrete Weigh the child on the same scale to gradually
Moderate blood membrane excessive fluid through at the same time daily. Monitor excrete excessive
- “Sa tuwing iihi pressure inhibiting urination intake and output accurately. fluid through
siya, parang increases filtration), urination and
may dugo o possibly b) Demonstrate R: Weight gain results from fluid demonstrated
dumi.” - Puffiness in evidenced by behaviors that would retention; Accurate measurement behaviors that
the face edema, intake help in excreting of intake and output helps assess would help in
- “Mataas din greater than excessive fluids in the fluid balance. excreting
ang prisyon - Intake greater output and BP body excessive fluids in
niya, parang than output changes. Encourage bed rest during the the body
hindi pambata.” Long term goals: acute stage, disturb only when
- Presence of - Risk for needed. Long term:
protein in urine impaired skin After 2 days of Goals are met after
integrity related thorough nursing R: Conserves energy and limits 2 days of thorough
to edema and intervention, the the production of waste materials nursing
patient will be able to; which increases the work of the
alteration in kidneys intervention.
skin turgor a) Display appropriate
urinary output with Elevate the edematous body part The client was be
- Altered specific while the child is in bed or sitting in able to;
urinary gravity/laboratory a chair.
elimination studies near normal; -Excrete
related to stable vital signs R: Helps move fluid away from completely
decreased within the client’s dependent body parts through excessive fluids as
bladder normal range; and gravity. manifested by the
capacity or absence of edema. absence of edema.
irritation Educate parents about dietary
secondary to b) Maintain cardiac inclusion and restriction; provide a - Display
infection output as evidenced by list of foods to include and avoid appropriate urinary
BP and HR/rhythm that comply with sodium, ouput with normal
within the client’s potassium, and protein specific gravity and
normal limits; allowances. laboratory status
peripheral pulses are within normal
strong and equal with R: Provides nourishment while the range.
adequate capillary refill disease is being resolved.
time. - Display normal
Explain to the child (as vital signs e.g BP
c) Experience no appropriate) and family about maintains within
signs/symptoms of acute glomerulonephritis, including the normal range.
infection. its signs and symptoms,
d) diagnostics, and management.
e) Display I&O near
balance; good skin R: Provides an understanding of
turgor, moist mucous the disease which increases
membranes, palpable compliance with the treatment
peripheral pulses, and regimen.
electrolytes within
normal range.