1. The patient has chronic kidney disease stage 5 with increased creatinine, BUN, and uric acid levels indicating impaired kidney function and fluid overload causing pulmonary congestion and edema.
2. Nursing interventions over 12 hours included monitoring vitals and fluid intake/output, assessing edema and shortness of breath, and restricting sodium/fluid intake to prevent further fluid overload.
3. After interventions, the patient's symptoms were reduced and they demonstrated behaviors to self-monitor fluid status and adhere to the treatment plan to manage their chronic kidney disease.
1. The patient has chronic kidney disease stage 5 with increased creatinine, BUN, and uric acid levels indicating impaired kidney function and fluid overload causing pulmonary congestion and edema.
2. Nursing interventions over 12 hours included monitoring vitals and fluid intake/output, assessing edema and shortness of breath, and restricting sodium/fluid intake to prevent further fluid overload.
3. After interventions, the patient's symptoms were reduced and they demonstrated behaviors to self-monitor fluid status and adhere to the treatment plan to manage their chronic kidney disease.
1. The patient has chronic kidney disease stage 5 with increased creatinine, BUN, and uric acid levels indicating impaired kidney function and fluid overload causing pulmonary congestion and edema.
2. Nursing interventions over 12 hours included monitoring vitals and fluid intake/output, assessing edema and shortness of breath, and restricting sodium/fluid intake to prevent further fluid overload.
3. After interventions, the patient's symptoms were reduced and they demonstrated behaviors to self-monitor fluid status and adhere to the treatment plan to manage their chronic kidney disease.
Assessment Diagnosis Inference Planning Intervention Rationale Evaluation Subjective: Nandito ako kasi nahihirapan akong huinga! "a"o na pag nagsasa"ita# as verba"i$ed by the patient %bjectives: &S taken as 'o""o(s: Temp: )*.+ RR: ,5cp PR: -)bp BP: .*/0../ Patient 1ani'ested: 2dea 3, 4ypertension Pu"onary Congestion 5S%6! D%67 %"iguria as evidence by .5/ " per +hours 8"uid &o"ue 29cess r0t sodiu retention :pairs g"oeru"ar 'i"tration increase hydrostatic pressure Pushing e9cess '"uids into the interstitia" spaces 8"uid vo"ue over"oads the "yph syste 2dea! pu"onary congestion and 4PN ;'ter <=+ hours o' nursing interventions patient (i"" deonstrate behaviours to onitor '"uid status and reduce recurrence o' '"uid e9cess .. 2stab"ish rapport ,. 1onitor and record vita" signs ). ;ssess patient>s appetite <. Note aount0rate o' '"uid intake 'ro a"" resources 5. ?ecord occurrence o' dyspnea *. Note presence o' edea @. ?estrict sodiu and '"uid intake i' indicated +. ?ecord : A% accurate"y and ca"cu"ate '"uid vo"ue ba"ance -. Proote .. Bo assess precipitating and causative 'actors ,. Bo obtain base"ine data ). Bo prevent '"uid over"oad and onitor intake and output <. Bo onitor '"uid retention and eva"uate degree o' e9cess 5. Bo deterine '"uid retention *. 1ay indicate increase in '"uid retention @. Bo onitor kidney 'unction and '"uid retention +. :ndicated '"uid retention and edea Bhe patient sha"" have deons= trated behaviours to onitor '"uid status and reduce recurrence o' '"uid e9cess overa"" hea"th easure -. Bo proote (e""ness Assessment Diagnosis Inference Planning Intervention Rationale Evaluation Subjective: Buataas ng tuataas yong 6CN at Creatinine ko! kaya ibes na da"a(ang beses "ang ako agdidia"ysis! sabi ng dokotor agiging )=< na# as verba"i$ed by the patient %bjectives: &S taken as 'o""o(s: Temp: )*.+ RR: ,5cp PR: -)bp BP: .*/0../ :ncrease in Dab resu"ts 56CN! Creatinine! uric ;cid Deve"7 as evidence by Creatinine: 5,/Eo"0D ;"tered ?ena" Per'usion r0t :ncrease in 6CN! Creatinine and Cric ;cid %ptia" ce"" 'unctioning! the kidney e9crete potentia""y har'u" nitrogenous product Doss o' kidney e9cretory 'unctions :paired e9cretion o' nitrogenous (aste :ncrease in Daboratory resu"t o' 6CN! Creatinine! Cric ;cid Deve" ;'ter ,=) hours o' Nursing :nterventions the patient (i"" deonstrate participation in her reco= ended treatent progra .. 2stab"ish ?apport ,. 1onitor and ?ecord &S ). ;ssess patient>s genera" condition <. ;scertain usua" voiding pattern 5. Note presence! "oca" intensity duration o' pain *. 1onitor 6P! ascertain patient>s usua" range @. Provide diet restriction as indicated! (hi"e providing adeFuate ca"ories +. 2ncourage discussion o' .. Bo get the cooperation o' the patient ,. Bo obtain base"ine data ). Bo obtain base"ine data <. Bo copare (ith current situation 5. 1ay indicate pain on a''ected organ *. G8? ay increase rennin and raise 6P @. Ca"ories to eet body>s need (hi"e restriction o' protein he"ps "iit 6CN +. Bo decrease an9iety about condition and correct his (ring ideas about condition -. Bo proote Bhe patient sha"" have deonstrated participation in her recoended treatent progra BU: ,+ g0d" Uric acid: <++ Eo"0D Pu"onary Congestion 4ypertension %"iguria as evidenced by .5/" per + hours 'ee"ings regarding prognosis or "ong ter e''ect o' discussion -. :denti'y Necessary changes in "i'esty"e and assist c"ient to incorporate disease anageent to ;DDs ./. ;ssess patient eotiona"0psy cho"ogica" 'actors a''ecting the current situation ... Proote overa"" hea"th easure (e""ness and 'urther progression o' cop"ication ./. Stress or depression ay be increasing the e''ect o' an i""ness or depression ight be the resu"t o' being 'orced into inactivity ... Bo proote (e""ness Assessment Diagnosis Inference Planning Intervention Rationale Evaluation Subjective: Nahihirapan ako sa pag ihi# as verba"i$ed by the patient %bjective: :ncrease in "ab resu"ts 56CN! Creatinine! Cric ;cid Deve"7 7 as evidence by Creatinine: 5,/Eo"0D BU: ,+ g0d" Uric acid: <++ Eo"0D G8?: .5 %"iguria as evidenced by .5/" per + hours Crinary ?etention :paired Crinary 2"iination r0t g"oeru"ar 1a"'i"tration "oss o' kidney 'unctions Decrease G8? Cannot e9crete nitrogenous product and '"uid :paired in Crinary e"iination ;'ter ,=) hours o' nursing interventions! the patient (i"" verba"i$e understanding o' condition .. 2stab"ish rapport ,. 1onitor and record vita" signs ). ;ssess pt>s genera" condition <. Deterine c"ients pattern o' e"iination 5. Pa"pate b"adder *. Deterine c"ient>s usua" dai"y '"uid intake @. 2ncourage to verba"i$e 'ear0concerns +. 2phasi$e the need to adhere (ith prescribe diet .. Bo get the cooperation o' the patient ,. Bo obtain base"ine data ). Bo kno( (hat prob"e and interventions <. Bo assess degree o' inter'erence 5. Bo assess retention *. Bo he"p deterine "eve" o' hydration @. %pen e9pression a""o(s c"ient to dea" (ith 'ee"ings and begin prob"e so"ving. +. Bo prevent aggravation o' disease condition Bhe patient sha"" have deonstrated participation in his0her recoended treatent progra