ASSESSMENT NURSING SCIENTIFIC INFERENCE

DIAGNOSIS
SUBJECTIVE: Excess fluid
 Lethargic volume related to
 Decreased urine decreased in
output regulatory
 Hematuria or mechanism (renal
blood in the urine failure)
 Blurred vision

OBJECTIVE:
 Decreased
albumin –
Hypoalbuminemia
below 3.5 to 5
g/dL
 Increased Lipids –
Hyperlipidemia
above 200 mg/dL
 Decreased
production of
urine – Oliguria
below 800-2000
ml/day
 (+) Periorbital
edema
 Weight gain
 Increased Blood
Pressure -
Hypertension
above 120/80
 PLANNING NURSING INTERVENTION
SHORT TERM:  Obtain complete physical
After an hour of nursing assessment
intervention:  Monitor fluid intake and
 Patient will have no output
elevation in blood  Monitor blood pressure and
pressure and will pulse rate every hour
maintain within  Assess for adventitious
normal range breath sounds
 Monitor laboratory values
LONG TERM: especially for the protein
After a month of nursing level in the urine
intervention:  Monitor daily weight
 Patient will have a  Administer antibiotics as
normal fluid balance ordered
and manifest lesser  Administer
edema antihypertensive as ordered
 Administer digitalis as
ordered
 Restrict fluid intake as
ordered
 Provide diversional therapy
 Provide client teaching and
discharge planning
concerning
 Medication
administration
 Prevention of infection
 Signs of renal
complications
 Importance of long-
term follow up
RATIONALE EVALUATION
 To have baseline data on the SHORT TERM:
progress of fluid elimination After an hour of nursing
through physical appearance intervention:
 To have a measurable account  Patient has no elevation
on the fluid elimination in blood pressure and
 To know progressing condition maintained within
through glomerular filtration normal range
 To know progression of
hypertension and basis for LONG TERM:
further nursing intervention or After a month of nursing
referral intervention:
 To know for possible  Patient has normal fluid
progression in the lungs balance and absence of
 To know the extent of protein edema
loss which led to edema
 For streptococcal infection
 If blood pressure severely
elevated
 If circulatory overload
 To prevent too much fluid in
the body that causes the
swelling
 If renal insufficiency
 To support, challenge, and
enhance the psychological,
spiritual, social, emotional, and
physical well-being of
individuals
 Provides an understanding of
the disease