ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Date: 03-08-24 Fluid volume Short Term: 1. Establish Rapport 1. To establish Short Term:
excess related to therapeutic
Subjective Data: After 1 hour of After 1 hour of nursing
kidney relationship with
nursing intervention the was able
Nakakainom ako ng mahigit dysfunction as the patient.
intervention the to verbalized
isang litro sa isang araw na evidence by (+3)
patient will 2. Assess vital signs 2. Help monitor understanding of strict
inumin pero hindi na ako gaano bipedal edema,
verbalize before and after the baseline data and limit fluid intake, patient’s
umiihi as stated by the patient. urine output of
understanding of therapy. identify blood pressure was
400ml .
Objective data: strict limit fluid complications. stabilized, and free from
intake, will 3. Assess and monitor bipedal edema.
Bp: 140/90 laboratory values. 3. To determine if
stabilize the
the condition
(+3) bipedal edema patient blood
improved or get
pressure, and the
Urine output : 400 ml in a day worsen.
patient will be
Creatinine: 1184 free from 4. Advice the patient 4. To help increase
Bipedal edema. to take foods rich in hemoglobin and
Current weight: 52KG.
iron and limit sodium hematocrit levels in
Dry weight: 50kg from the diet. the blood and to
prevent worsening
the condition.
5. Strictly advice the 5. Restricting
patient to follow the sodium favors renal
fluid limit intake and excretion of excess
diet plan. fluid and may be
more useful than
fluid restriction.
6. Weight the patient 6. If weight is rising
before and after the daily, fluid is being
hemodialysis. Or on retained, instruct in
regular basis. ways to keep tract
of I and O.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Date: 03-08-24 Ineffective Tissue After 1 month of 1. Establish 1. To establish After 1 monthof nursing
Perfusion related nursing Rapport therapeutic intervention, the patient
Subjective Data:
to decreased intervention, the relationship has improved tissue
“Nahihilo ako madalas at hemoglobin and patient will have with the perfusion status and
mababa ang Hemoglobin ko hematocrit levels an improved patient. displayed improvement in
sabi ng nurse”, as verbalized secondary to tissue perfusion 2. Help monitor laboratory values.
renal failure as status and will 2. Assess vital baseline data
by the patient.
evidenced by display signs before and identify
Objective Data: weakness, fatigue, improvement in and after the complications.
pallor, and laboratory therapy. 3. To determine
► Laboratory Results:
capillary refill values. 3. Assess and if the
• Low Hgb (10) time of >3 monitor condition
seconds. laboratory improved or
• Low Hct (31%) values. get worsen.
• Low RBC (3.28) 4. Assess 4. To assess
capillary refill circulation
• High Neutrophils (73.27) time. and peripheral
• Low lymphocytes (16.83) perfusion.
• High creatinine (1184) 5. To help
5. Advice the increase
► Restlessness patient to take hemoglobin
foods rich in and
► Pallor iron and limit hematocrit
► Capillary Refill Time of >3 sodium from levels in the
seconds the diet. blood and to
prevent
worsening the
condition.
6. To stimulate
 6. Encourage red blood cell
EPO injection production,
as prescribed alleviating
by anemia and
nephrologist reducing the
need for blood
transfusions.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Impaired Urinary After 15–30 minutes Independent: After 15–30 minutes
Elimination of nursing of nursing
“Umiinom ako ng  Monitor fluid  Calculate fluid
related to the intervention, the intervention, the
1 liter maghapon intake and balance to
progressive patient will be able ensure patient was able to
tapos yung ihi ko output closely.
decline in kidney to understand the adherence to understand the
parang nasa Restrict fluid
function as regimen to slow prescribed limits regimen to slow
kalahati lang ng intake as
evidenced by down the and to prevent down the
500 ml na prescribed.
elevated serum progression of CKD fluid overload. progression of CKD
mineral water” as
creatinine. and prevent further and prevent further
verbalized by the
complications complications
patient.  Educate the  To manage
related to renal related to renal
Objective: function. patient and renal failure and function.
family about prevent
>Oliguria (U/O of the importance complications GOAL MET!
less than 400 ml of medication
in 24 hours) adherence,
dietary
>Creatinine
restrictions,
(1184 umol/L)
and lifestyle
modifications
  Providing
 Offer emotional
Emotional support and
Support and anxiety
Reduce reduction
Anxiety techniques,
such as
relaxation
exercises, can
help improve
the patient's
overall well-
being.

 Ensure the
 Encourage patient
Regular schedules and
Follow-Up attends regular
Appointments follow-up
appointments to
monitor CKD
progression,
kidney function,
and urinary
elimination.
Dependent:
 To control blood
 Administer pressure and
amlodipine as manage
prescribed. symptoms.
 Collaborative:

 Collaborate  To educate the

with a dietitian. patient about
dietary
restrictions,
particularly
those related to
sodium,
potassium, and
phosphorus
intake.

 Collaborate  To ensure that

with the patient's
nephrologists, care plan aligns
dietitians, and with overall
other CKD
healthcare management.
professionals.