GROUP 8

BSN-2201
 CASE STUDY

A woman, pregnant at 28 weeks, is diagnosed to have chronic

kidney disease. For the past 8 hours, the following
observations were noted by the nurse: bipedal edema, urine
output of 125 cc, and a BP of 170/100 mmHg. She is
undergoing dialysis of 2 sessions per week, and blood
transfusion of 1 pack RBC for every dialysis session. Create
a nursing plan for this scenario.
 Chronic Kidney Disease

This is also called as chronic kidney failure, describes the

gradual loss of kidney function. Your kidneys filter wastes
and excess fluids from your blood, which are then excreted
in your urine. When chronic kidney disease reaches an
advanced stage, dangerous levels of fluid, electrolytes and
wastes can build up in your body.
Objective Data:
Bipedal edema
 Nursing Diagnosis:
Excess Fluid Volume related to
Renal Insufficiency secondary to
Chronic Kidney Disease
 Assessment Nursing Planning Interventions Rationale Evaluation
Diagnosis

Objective Data: Excess Fluid After 8 hours of • Minimize oral • To minimize

 Bipedal edema Volume related nursing fluid intake. presence of
to Renal intervention, the edema.
Insufficiency patient will be
secondary to able to: • Suggest  To reduce
Chronic Kidney interventions discomfort of
Disease -reduce the such as fluid
presence of frequent oral restriction.
edema. care, and
chewing gum
-understand the or hard candy.
measures in
preventing fluid • Instruct the  To manage
volume excess. patient about fluid
the dietary retention.
restriction in
sodium
Assessment Nursing Planning Interventions Rationale Evaluation
Diagnosis

• Emphasize the • To prevent

need to adhere aggravation of
with the disease
prescribed condition.
diet.

• Advise patient • To prevent

to elevate feet and lessen
when sitting fluid
down accumulation
in lower
extremities.

• Advise the • To reduce

patient to tissue
change pressure and
position risk of skin
frequently. breakdown.
.
Assessment Nursing Planning Interventions Rationale Evaluation
Diagnosis

• Press the • To determine

lower if there are
extremities for still excess
about 15 fluids. If the
seconds every skin is
hour. pressed for
15 seconds
and there is
an
indentation,
it means that
the patient is
still
edematous.
Assessment Nursing Planning Interventions Rationale Evaluation
Diagnosis

• Encourage • Wearing After series of

patient to stockings interventions, the
wear promotes patient was able
compression blood flow to:
stockings from legs to
(anti- the heart -lessen the
embolism which swelling of the
stockings) at reduces lower extremities.
some time if edema.
not restricted. -verbalized
understanding of
 Give diuretics • To reduce the measures to
as prescribed excessive prevent fluid
by the fluid in the volume excess.
physician. body.
Goal was met.
 Refer to a • To plan the
dietician. appropriate
diet for the
patient.
GROUP 8
Precious Atienza

Piola Del Mundo

Madelaine Evangelio

Manel Lat

Alyssa Morales

Jane Teñoso