You are on page 1of 2

Assessment

Subjective:
Nagmamanas lang ako
nung una at ngayon naman
ay minsan nahihirapan na
akong huminga (I am
only having edema before
but now sometimes I have
some difficulty in
breathing...) verbatim of
client.
Objective:
Easy fatigability
Weakness
Shortness of breath
Weight gain as claimed
Anorexia
History of
glomerulonephritis when she
was still a child
Urinalysis showed
proteinuria
Hematologic lab results
indicate decreased Hgb and
Hct counts.
Latest blood pressure :
150/100mmHg
Latest respiratory rate:
25 breaths/min.

Nursing Diagnosis

Inference

Impaired Gas Exchange


related to decreased red
blood cell production
and reduction in the
oxygen carrying
capacity of the blood
secondary to disease
process.

Renal failure affects the


function of the kidneys. It
is a gradual progressive
condition which primarily
a result from ischemia,
inflammatory processes,
or nephrotoxicity.
The destruction in the
glomerular filtration
basically influences the
ability of the kidneys to
filter the blood flowing in
the renal blood vessels. In
addition, the damage in
the nephrons progresses
and its ability to secrete
erythropoietin decline.
Erythropoietin is a
hormone that prompts the
bone marrow increase red
blood cell production.
Obviously, the decline in
renal function often leads
to chronic anemia.

NURSING CARE PLAN FOR RENAL FAILURE


Outcome
Nursing Interventions
-Assess clients
After 8 hours of
respiratory rate, depth and
nursing care, the
use of accessory muscles.
client will be able to
show an improved gas - Monitor vital signs and
exchange as
check for fluctuations in
evidenced by
RR, PR, and BP. Presence
decreased episodes of of hypovolemia may show
dyspnea/ shortness of a drop in BP and some
breath and improved
tachycardia.
tolerance to simple
activity.
- Assess ability and
tolerance to activity; assist
client in ambulation or
limit stressful activity
depending on clients
tolerance.
-Place client in fowlers
position, elevating head
while maintaining
comfort.
- Provide supplemental
oxygen as indicated, i.e.
O2 at 2liters per min.
-Provide a quiet non
stimulating environment.
-Assist in transfusion
therapies as indicated.

Rationa
- Provides basel
of clients comp
degree of respira
compromise.
- It could help as
clients need for
transfusion thera

-Assisting client
limiting activity
reduce the oxyg
demand of the b
reducing shortne
breath episodes.
- Placing client i
fowlers position
the proper chest
expansion.

-Supplemental o
aids in minimizi
increased need o
body for oxygen
depending on sit
requirement.
- It promotes ad
resting periods f
client.
-Chronic anemia
failure is treated
transfusion of bl
compensate for

compromise.

You might also like