Medical Diagnosis: Chronic Kidney Disease Stage 5
Patient’s name: Patient J.P.
Assessment Diagnosis Inference Planning Intervention Rationale Evaluation
Subjective: Fluid Impairs After 4-8 1. Establish 1. To assess The patient
Volume glomerular hours of rapport precipitating shall have
“Nandito ako kasi Excess r/t filtration nursing 2. Monitor and and causative demons-
nahihirapan akong sodium interventions record vital factors trated
huminga, lalo na pag retention increase patient will signs 2. To obtain behaviours
nagsasalita” as hydrostatic demonstrate 3. Assess baseline data to monitor
verbalized by the pressure behaviours patient’s 3. To prevent fluid fluid status
patient to monitor appetite overload and and reduce
Pushing fluid status 4. Note monitor intake recurrence
Objectives: excess and reduce amount/rate and output of fluid
VS taken as fluids into recurrence of of fluid 4. To monitor fluid excess
follows: the fluid excess intake from retention and
Temp: 36.8 interstitial all evaluate
RR: 25cpm spaces resources degree of
PR: 93bpm 5. Record excess
BP: 160/110 Fluid occurrence 5. To determine
volume of dyspnea fluid retention
Patient Manifested: overloads 6. Note
Edema +2 the lymph presence of 6. May indicate
Hypertension system edema increase in
Pulmonary 7. Restrict fluid retention
Congestion Edema, sodium and
(SOB, DOB) pulmonary fluid intake if 7. To monitor
Oliguria as congestion indicated kidney function
evidence by and HPN 8. Record I &O and fluid
150 ml per accurately retention
8hours and
calculate 8. Indicated fluid
fluid volume retention and
balance edema
9. Promote
overall 9. To promote
health wellness
measure
Assessment Diagnosis Inference Planning Intervention Rationale Evaluation
Subjective: Altered Optimal cell After 2-3 1. Establish 1. To get the The patient
“Tumataas ng Renal functioning, hours of Rapport cooperation of shall have
tumataas yong BUN Perfusion the kidney Nursing 2. Monitor and the patient demonstrated
at Creatinine ko, r/t Increase excrete Interventions Record VS 2. To obtain participation in
kaya imbes na in BUN, potentially the patient 3. Assess baseline data her
dalawang beses Creatinine harmful will patient’s 3. To obtain recommended
lang ako and Uric nitrogenous demonstrate general baseline data treatment
magdidialysis, sabi Acid product participation condition 4. To compare program
ng dokotor magiging in her recom- 4. Ascertain with current
3-4 na” as Loss of mended usual voiding situation
verbalized by the kidney treatment pattern 5. May indicate
patient excretory program 5. Note pain on affected
functions presence, organ
Objectives: local intensity 6. GFR may
VS taken as Impaired duration of increase rennin
follows: excretion of pain and raise BP
Temp: 36.8 nitrogenous 6. Monitor BP, 7. Calories to
RR: 25cpm waste ascertain meet body’s
PR: 93bpm patient’s usual need while
BP: 160/110 Increase in range restriction of
Increase in Laboratory 7. Provide diet protein helps
Lab results result of restriction as limit BUN
(BUN, BUN, indicated, 8. To decrease
Creatinine, Creatinine, while anxiety about
uric Acid Uric Acid providing condition and
Level) as Level adequate correct his
evidence by calories wring ideas
Creatinine: 8. Encourage about condition
520μmol/L discussion of 9. To promote
BUN: feelings wellness and
28 mg/dl regarding further
Uric acid: prognosis or progression of
488 μmol/L long term complication
effect of 10. Stress or
Pulmonary discussion depression may
Congestion 9. Identify be increasing
Hypertension Necessary the effect of an
Oliguria as changes in illness or
evidenced by lifestyle and depression
150ml per 8 assist client to might be the
hours incorporate result of being
disease forced into
management inactivity
to ADLs 11. To promote
10. Assess wellness
patient
emotional/psy
chological
factors
affecting the
current
situation
11. Promote
overall health
measure
Assessment Diagnosis Inference Planning Intervention Rationale Evaluation
Subjective: Impaired loss of kidney After 2-3 1. Establish 1. To get the The patient
Urinary functions hours of rapport cooperation shall have
“Nahihirapan ako Elimination r/t nursing 2. Monitor and of the patient demonstrated
sa pag ihi” as glomerular Decrease interventions, record vital 2. To obtain participation in
verbalized by the Malfiltration GFR the patient will signs baseline data his/her
patient verbalize 3. Assess pt’s 3. To know recommended
Cannot understanding general what treatment
Objective: excrete of condition condition problem and program
Increase in nitrogenous 4. Determine interventions
lab results product and clients 4. To assess
(BUN, fluid pattern of degree of
Creatinine, elimination interference
Uric Acid Impaired in 5. Palpate 5. To assess
Level) ) as Urinary bladder retention
evidence by elimination 6. Determine 6. To help
Creatinine: client’s usual determine
520μmol/L daily fluid level of
BUN: intake hydration
28 mg/dl 7. Encourage to 7. Open
Uric acid: verbalize expression
488 μmol/L fear/concerns allows client
GFR: 15 8. Emphasize to deal with
Oliguria as the need to feelings and
evidenced adhere with begin
by 150ml prescribe diet problem
per 8 hours solving.
Urinary 8. To prevent
Retention aggravation
of disease
condition
